University Of California Los Angeles Policy Analysis Models Discussion


To prepare: Review this week’s Learning Resources, and consider the different types of policy analyzes that might apply to the scenario. Review the economic study, entitled “Child Food Insecurity: The Economic Impact on our Nation,” found in the Week 4 Learning Resources. Reflect on the scenario provided, and your postings, from the Week 4 Discussion. Consider the continuation of the scenario below: This time, you are a policy analyst for South Central City. The city manager has requested you select and apply a policy analysis model to develop an executive summary in response to the city’s concerns related to food insecurity. Select the one policy analysis model you think is best to apply to the above scenario. Access the Walden General Templates link, in the Learning Resources, and use the APA Course Paper Template for this Assignment. Assignment: (1–2 pages, not including reference and title pages) Write an executive summary for the South Central city manager. In it, address the concerns raised by the various stakeholders. Your executive summary should include the following: A summary of the problem A description of the model you are recommending for policy analysis, taking into account the culture and politics of the city A critical assessment as to why the model will most strongly address the food insecurity concerns of South Central City.

The Executive Summary (1-2 pages) will eventually be given to judges at the SemiFinals and Final Round of the competition. Your document should quickly summarize:
the problem, your idea, and the benefits of your solution. The format can be a bulletpoint list or it can contain more graphics. For your first draft, focus on content rather
than design; make sure to include the basics of your project and the summary of your
solution. For the revised drafts, focus more on the design and the function of this piece
of paper as a takeaway for the judges.
See five great examples below!
The creation of The School Redevelopment Authority will revitalize communities
across Philadelphia that are the victims of closing schools and shifting demographics.
The goal of the SRDA is to acquire and develop the former school buildings. After performing light
modifications and low-cost improvements, the SRDA will divide and lease the buildings to a mix of
tenants–both non-profit and for-profit–to create a balanced, income producing portfolio.
Our innovation is in the market-based approach to asset management. Working under the
Philadelphia Redevelopment Authority, and in collaboration with neighbors, community leaders and
potential investors, the SRDA decides on a theme for the redevelopment of each building:
The schools will house community clinics, counseling centers and low-cost
healthcare facilities improving the health and wellness of communities.
A home for business incubators, entrepreneurship hubs, small workshare
office space and neighborhood internet and computer centers, bringing
economic vibrancy and opportunity to Philadelphia neighborhoods.
Transformed into artist studios, workshop spaces, small-scale manufacturing
and fabrication facilities, the school buildings will house up-and-coming
artists and micro-industries.
A place for community gardens, grocery stores, weekend farmer’s markets,
and local food entrepreneurs, these programs will address the expansive
‘food desert’ throughout low-income neighborhoods in Philadelphia.
Allows school buildings to be used for a mix of educational and recreational
purposes, such as athletic facilities, day care centers, nursery schools,
charter schools and adult education classrooms.
Fels Policy Challenge 2012
Team 9
Closing Schools, Opening Opportunities
¡Habilita! (Empower!)
Lee Every • William Moen • Thomas Molieri • Marissa Prianti • Jason Riley
In the past decade, the Latino population of Philadelphia has increased by 46% to 181,292 people, or
12.3% of the city’s overall population. The majority (68.3%) of school-aged Latinos are enrolled in the city’s
public schools. Their performance, however, is dismal, with only 43% of Latinos graduating high school in
four years. Given that the School District of Philadelphia (SDP) has made layoffs in the past year, endured a
very public management crisis, and faces an additional $629 million in cuts this year, there is a clear need for
innovative approaches to enhance student performance without further burdening the district.
A significant body of research links parents’ involvement in their children’s educations to student
success in the classroom. Philadelphia’s Latino population faces significant barriers to this involvement,
including a language barrier, low parental literacy rates, and lack of computer literacy/access among parents, to
name a few.1
Facing many of the same challenges, the Denver school system launched “La Educa” in 2009. La Educa
is a radio program that airs three times per week on a Spanish language station. It informs parents of what is
taking place in the district, the rights and responsibilities of students and parents, and features a call in session
that allows parents to direct content. The initiative was based on the idea of meeting Latino parents where they
are. Many work in service industry occupations where they have access to radio throughout the day. In its first
year, La Educa had 54,200 listeners. Today, the show averages approximately 100 callers per month.
The Denver program is run out of the Denver Public School District’s Office of Multicultural Affairs.
We propose to launch a similar initiative in Philadelphia, but with a different model. As noted above, SDP is
not in a position to take on new programming. There is, however, a very active network of Latino advocacy
organizations that can be leveraged to develop a partnership between Spanish language radio, community
development organizations, and SDP to make this initiative a success.
The Denver Public School District has offered its support and guidance in the development of this
initiative. We have begun conversations with Latino community organizations including Juntos and Congreso
de Latinos Unidos. The Spanish language radio station El Voz has agreed to partner on the initiative, including
production of the show, provision of the on-air talent, and air time. Members of the School Reform
Commission have agreed to meet with our team to brainstorm the model, partners, marketing, and funding.
Additionally, the Archdiocese of Philadelphia’s Office of Multicultural Affairs has offered advertising support,
and SDP’s Multilingual Family Support Office has pledged programming assistance.
At this stage, we envision a Spanish language radio program for parents that will keep them informed of
what is happening in the school district, and provide them with the knowledge and resources necessary to
participate more fully in their children’s educations. We will also explore the possibility of podcasts. Both the
radio program and potential podcasts would be implemented at no cost to the city or SDP.
1 Parental Involvement and Student Achievement: A Meta-Analysis by William Jeynes, Family Involvement Research Digests,
December 2005. Accessed at
Parental Effort, School Resources, and Student Achievement by Karen Conway and Andrew Houtenville, Journal of Human
Resources, Spring 2008. Accessed at
Closing Gaps in Mental Health Continuity of Care
Executive Summary
re:Mind is an appointment reminder service targeting individuals discharged from inpatient mental
health hospitalizations. re:Mind calls for the creation and adoption of a cheap, simple, and researchsupported intervention that addresses the #1 reason patients miss their initial appointment—forgetting.
By facilitating successful establishment of outpatient care, re:Mind has the potential to save the City
millions of dollars in wasted time and preventable hospitalizations, while preserving the mental health of
thousands of our fellow Philadelphians.
● Short term: improve initial outpatient mental health appointment attendance rates.
● Intermediate term: decrease rates of re-hospitalization, shorten wait time for initial
appointments, reduce lost revenue and health care costs associated with no-show and
● Long term: improve lifetime outcomes for mental health consumers, create a “pathway to policy”
for future policy initiatives.
In Philadelphia, hospitals discharge upwards of 11,000 patients every year from inpatient acute
psychiatric care.i As part of a movement towards recovery-oriented treatment, the standard practice
is to ensure continued care by scheduling an appointment in advance of discharge connecting
patients to an outpatient provider.ii However, on average only 42% of those initial appointments are
kept.iii Research indicates that the most common single reason cited for non-attendance at mental
health follow-up appointments is forgetting the appointment.ivv
Serious mental illnesses generally require long-term treatment to maintain Patients who miss
their initial outpatient appointment are less likely to adhere to their medications and treatment plansvii
and up to 50% of patients who miss appointments drop out of scheduled careviii. Newly discharged
patients who do not attend follow-ups have been reported to have a two- to three-fold increase in the
rate of readmission compared with those who remain in contact with services.ixx Patients who miss
their initial follow-up appointment have a 1 in 4 chance of being re-hospitalized in 12 months (vs. 1 in 10
if they keep the appointment).xi In Philadelphia, the cost of re-hospitalization for patients who
missed their follow-up appointments is roughly $9,429,000 annually.xii
Dropping out of treatment has devastating consequences for many stakeholders:
● Patients and Communities- without continued care, mentally ill individuals face an increased
risk of unemployment, homelessness, and becoming a threat to themselves or others. 24%
of suicides by the mentally ill occur within a month of discharge from hospital.xiii
● Outpatient Providers- missed appointments mean lost revenue, lowered ability to attract
qualified mental health employees, and longer wait times until the next available appointment.
● Medicaid- as the largest payer of mental health services in the US,xiv waste in mental health
services translates to a waste of public funds.
● Other Patients- missed appointments create longer wait times to the next available
appointment, which in turn decreases the likelihood the appointment will be keptxv
Fels  Public  Policy  Challenge  2013  
Using software licensed from, the re:Mind service will exist as a
website,, available to hospital discharge planners. With a simple, user-friendly
interface, it will take users a maximum of five minutes to enter necessary contact and appointment
information. The website will then automatically generate two reminder phone call attempts, two text
messages, and an email in advance of the patient’s appointment.
The service is based on findings that reminders reduce no-shows by 28-36% among psychiatric
patients.xvi xvii Text messaging offers a rapid, cost-effective, and desirable means to deliver
reminders.xviiixix Research suggests patients may find text messaging less intrusive than phone calls.xx
In a pilot study involving 1,256 patients in 4 British psychiatric outpatient clinics, text reminders reduced
did-not-attend status by 25-28% compared to the year prior to the intervention.xxi Only 0.1% of patients
opted out. The authors of this study estimate that text message reminders could have an annual cost
savings of $245 million USD in England.
Implementation of re:Mind tackles the systemic barriers to improving patient care by targeting two of its
biggest stakeholders: hospital social service departments, who will be charged with using the service,
and Community Behavioral Health (CBH), the not-for-profit organization contracted by the Department
of Behavioral Health to provide behavioral health coverage for the City’s 420,000 Medicaid recipients.
CBH will be charged with long-term project management.
● Budget
○ $8,500 for the creation of the website
○ $250 monthly to license the reminder software ($3,000 annually)
○ $500 annually for website updating, repairs, and hosting fees
○ $7,500 for 1 temporary staffer to supervise project development and stage an education
campaign targeting Philadelphia’s 23 inpatient psychiatric care facilities
○ TOTALS: $19,000 startup costs, $3500 annual maintenance
● Initial startup costs: re:Mind will lobby for the creation of a ”Special Initiative” through the
Department of Behavioral Health and Intellectual disAbility Services (DBHIDS).
● Long-term maintenance: re:Mind system maintenance and data mining will become the
responsibility of existing employees within CBH’s Continuous Quality Improvement (CQI)
● Carrot: re:Mind will launch an education campaign targeting hospital social service
departments, using the research to appeal their sense of altruism, efficacy, and efficiency.
● Stick: re:Mind will engage CBH in incorporating re:Mind into their utilization manual, making
the use of re:Mind a mandatory element in receiving reimbursement for discharge planning.
● If re:Mind helps just two patients continue with treatment, it has already recouped its costs.
● If Philadelphia reduces no-shows at a rate similar to the British pilot study that serves as
its model, there would be an estimated annual savings of $2,360,000.xxii
Fels  Public  Policy  Challenge  2013  
Commonwealth of Pennsylvania Department of Public Welfare. (2010). Readmission within 30 days of inpatient psychiatric discharge.
Retrieved from
Community Behavioral Health. (2012). Aftercare & discharge planning. Utilization Manual, p. 116.
Rajasuriya, M., De Silva, V., & Hanwella, R. (2010). Effectiveness of reminders in reducing non-attendance among out-patients. The
Psychiatrist, 34, 515-518.
Mitchell, A. J., & Selmes, T. (2007). Why don’t patients attend their appointments? Maintaining engagement with psychiatric services.
Advances in Psychiatric Treatment, 13, 423-434.
Killapsy, H., Banerjee, S., King, M., & Lloyd, M. (2000). Prospective controlled study of psychiatric out-patient non-attendance. The
British Journal of Psychiatry, 176, 160-165.
Kreyenbuhl, J., Nossel, I., & Dixon, L. (2009). Disengagement from mental health treatment among individuals with schizophrenia and
strategies for facilitating connections to care: A review of the literature. Schizophrenia Bulletin, 35(4), 696-703.
Sims et al (2012). Text Message Reminders of Appointments: A pilot intervention at four community mental health clinics in London.
Psychiatric Services. 63(2):161-168.
Mitchell & Selmes, 2007.
Koch, A., & Gillis, L. S. (1991). Non-attendance of psychiatric outpatients. South African Medical Journal, 88, 289-291.
North Sound Mental Health Administration. (2012). Improved delivery of non-crisis outpatient appointments after a psychiatric
hospitalization. Nonclinical Performance Improvement Project. Retrieved from
p. 3.
MItchell & Selmes, 2007
Amount based on the following estimates: of the 11,584 Philadelphia patients discharged from inpatient psychiatric care, 20-42% of
them miss their appointment, 25% of those will be rehospitalized, and average hospitalization cost of $1400 per diem with an average
length of stay of 7.5 days. Data gathered from Center for Disease Control and Prevention. (2009). National hospital discharge survey:
2009 table, average length of stay and days of care – number and rate of discharges by first-listed diagnostic categories. Retrieved from
Commonwealth of Pennsylvania Department of Public Welfare.
Mitchell & Selmes, 2007
Shirk, C. (2008). Medicaid and mental health services. National Health Policy Forum, Background Paper, 66, 1-19.
Mitchell & Selmes, 2007
Rowett, Rewa and Makhoul, 2010
Rajasuriya, M., De Silva, V., & Hanwella, R., 2010
Sims et al (2012)
McLean, S. & Perera, M. (2012). The Use of Short Message Service (SMS) For Patient Appointment Reminders. JMTM. 1(3):53-55.
McLean & Perera, 2012
Sims et al, 2012
If similar results were demonstrated in Philadelphia , 898 additional people would now make it to their first appointment, reducing
their chance of returning to the hospital within 6 months from 1 in 4 to 1 in 10, leading to an estimated $8,484,000 in savings based on
the average length of a hospital stay and the average per diem rate of Philadelphia area hospitals, as outlined in footnote xii.
Fels  Public  Policy  Challenge  2013  
2013 Public Policy Challenge
Team 1: Executive Summary
Faith in Farmers Winter Market Initiative
In recent years several programs have emerged to deal with food deserts and the lack of healthy
affordable foods in lower income communities around the city. Organizations like the Philadelphia Food
Trust and Farm to City have established different programs and created weekly farmers’ markets in
traditionally underserved neighborhoods. However, what happens when winter hits and the markets retire
for the season?
Our proposal, the Faith in Farmers Winter Market Initiative, provides low-income neighborhoods access
to freshly grown foods within the centerpiece of their community – the local church, synagogue, temple
or mosque. After or between weekend services, local farmers will set up indoor markets within the
religious facility. Community members, both within and from outside the congregation, can then
purchase produce, meats and dairy as they would at a spring or summer market. Participating vendors
will have to be equipped with EBT (electronic benefit transfer) devices to accept SNAP (Supplemental
Nutrition Assistance Program) and WIC (Women, Infants and Children Program) cards. Fortunately,
vendors currently participating in Philadelphia farmers’ markets already have EBT devices, most through
the state-administered Farmers’ Market Nutrition Program.
Program Benefits
While establishing a new market of any kind bears risk, connecting religious institutions with local
farmers to address a public health problem offers several advantages:
1. Fresh food access for low-income Philadelphians is broadened with minimal involvement of the
city government
2. Local farmers are provided new markets during typically slow winter months
3. The concentration of residents at weekend services ensures a reliable consumer base for
participating farmers
4. Farmers’ markets are effective in community building and disseminating nutrition education
5. The program would require minimal start-up funding and the mutually beneficial partnership
between farmers and the host organization should sustain the enterprise
Proven Success
Similar programs have thrived in major cities like Chicago and Washington D.C. as well as small towns
like Dubuque, Iowa. Many successful programs have begun with small handfuls of vendors but grew
quickly as residents became accustomed to the availability of freshly grown foods. Both in Chicago and
D.C., winter farmers’ markets hosted by churches now boast 8 to 30 vendors per market; meanwhile, new
markets are being created each year to satisfy demand. Most importantly, research has suggested that
farmer’s markets produce results in lower-income communities. A recent study of farmer’s markets in an
underserved Los Angeles neighborhood boasted positive feedback from residents:

75% came to market to do more than shop.
55% felt the market increased their connection to the community.
99% believed the market improved the health of the community.
Such ancillary benefits to the community only strengthen the argument for creating a winter program in
Philadelphia. The success of the program depends on piquing the interest of local farmers and host
organizations while helping coordinate between the two – requirements that are not only realistic but
possible in the short-term.
Scope and Operation
Currently, there are five winter markets coordinated by Philadelphia’s Farm to Table organization, three
of which are within the Philadelphia metropolitan area. These markets are located in Rittenhouse Square,
Suburban Station and Chestnut Hill. Our initial goal would be to add at least two new markets in lowerincome areas, as defined by the Census Bureau’s 2011 median annual household income in Philadelphia.
These would be small markets, with at least two vendors at each location. Our group would spearhead the
project, but aim to work with organizations like the Food Trust in a consulting capacity. It is unlikely that
much staffing would be required, as vendors already pay staff to sell at markets and most religious
organizations can find members to volunteer for community functions. Initial funding would be used to
pay for promotion and any unforeseen incidental expenses. We believe that if work were to begin this
spring, the program could launch the new winter markets by January of 2014.
Immediate Plan of Action
Given the limited financial resources required to push forward with the program, we may
immediately begin work on the following:
1. Contact the ten local farmers currently participating in Philadelphia-area markets to gauge interest
in additional business opportunities during the winter
2. Contact the Mayor’s Office on Faith Based Initiatives for clarity on how public services may be
delivered through a relationship with the religious community.
3. Target 2-3 potential host religious organizations in two lower-income areas.
4. Discuss potential costs and feasibility concerns with the Philadelphia Food Trust and Farm to
5. Evalaute potential funding sources, such as the The Pennsylvania Fresh Food Financing Initiative
(FFFI) and the Healthy Food Financing Initiative (HFFI), both administered through The
Reinvestment Fund.
Penn  Public  Policy  Challenge  Group  10  
Smart Justice: Probation and Parole Kiosks for Philadelphia
Key Terms
Probation: Probation is an alternative to incarceration in which the offender is permitted to serve the
entire sentence in the community.  
Parole: Parole is an alternative to continued incarceration in which the offender is permitted to serve
the remainder of the sentence in the community.  
Low Risk Offender: Any offender deemed, by a widely used set of assessments, highly unlikely to
commit a violent crime within the next two years. By definition, these are the least worrisome
offenders supervised by Philadelphia Adult Probation and Parole (APPD). There are roughly 12,000
low risk probationer and parolees in Philadelphia at any given time. Low risk offenders are also those
most likely to succeed and often require less assistance.  
Kiosk: A device similar in appearance to an airport check-in kiosk (see
picture and handout) on which probationers sign in using their fingerprint,
answer all the standard questions that Probation or Parole Officers (PO’s) ask
during in-person meetings, indicate issues or a desire to contact their PO, and
receive personalized messages from their PO’s.  
The Current State of Probation and Parole
Low risk offenders on probation or parole must travel from their neighborhoods to APPD’s location
in Center City (see the handout), where they often wait for hours for what is no more than a fifteenminute appointment. This system is inconvenient for the probationer or parolee, and it is also
extraordinarily time consuming for the PO’s, who typically manage approximately 350-400
individual cases at any given time. Under the current system, PO’s must spend a majority of their
time rushing through these meetings, with little time left for probationers and parolees who need
extra help.
Penn  Public  Policy  Challenge  Group  10  
Our Solution
Based on a solution already enacted by New York City and Washington, D.C., we propose a kiosk
system for low risk probationers and parolees. Kiosks would be placed within the neighborhoods
with the highest concentrations of probationers and parolees, allowing them to check in with the
APPD more easily, and freeing up Probation Officers to spend a greater amount of time with highrisk individuals who are more likely to recidivate or their low risk charges that need or seek more
1. To increase compliance with probation and parole for low risk offenders. Offenders will no longer
need to travel to Center City to meet with their PO’s. Instead, there will be an easily reached kiosk
within their neighborhood, and thus they will be more likely to report regularly.
2. To increase the likelihood that low risk offenders will achieve legal means of employment and a
healthy lifestyle. Kiosks will enable those who truly need additional support to connect with their
PO’s (who will have more time due to the lighter meeting schedule) and allow those who have
acquired jobs to work with minimal interference.
3. To increase resources for high risk offenders by freeing up PO’s. PO’s will have a greater impact
on recidivism rates if they can focus on high risk offenders and low risk offenders who need or want
extra help.
4. To keep better records of probationer and parolee information through digitization.
5. To create a more efficient and cost-effective probation and parole system in Philadelphia.
6. To increase the use of probation and parole as an alternative to jail and prison sentences. Like
many prisons and jails throughout the U.S., Pennsylvania’s prisons and jails are overcrowded. Use of
intermediate sanctions in place of incarceration is vital to fixing this problem. If our program is
successful, Philadelphia decsionmakers can be more confident that probation and parole are viable
alternatives to incarceration.
7. To increase the use of probation and parole nationally through a more successful system in
Philadelphia, and to increase the use of kiosks, which would greatly benefit areas even more spread
out than Philadelphia, such a large rural counties.
Child Food Insecurity:
The Economic Impact on our Nation
A report on research on the impact of food insecurity and hunger on
child health, growth and development commissioned by Feeding America
and The ConAgra Foods Foundation
John Cook, PhD, Project Director
Karen Jeng, AB, Research and Policy Fellow
01 Child Hunger is a Health Problem
02 Child Hunger is an Educational Problem
02 Child Hunger is a Workforce and Job Readiness Problem
06 Relationship of Food Insecurity of Poverty
09 What Are Food Security, Food Insecurity, and Hunger, and How Are They Related?
10 Do Food Insecurity and Hunger Matter?
10 A
10 Human Capital Theory
10 Initial Human Capital Endowment
11 The Role of Education in Human Capital Formation
11 Health and the Enhancement, Preservation and Destruction of Human Capital
11 Households as Producers
11 Households Production of Human Capital
11 Food Security as Human Capital and Household Production Input
12 The Prenatal and Neonatal Periods
13 Low Birthweight
14 Early Childhood: Ages 0-3 Years
15 Food Insecurity and Adverse Health Outcomes in Your Children
15 Child Food Insecurity Intensifies Adverse Effects of Household Food Insecurity
16 Child Food Insecurity and Iron Deficiency
16 Connecting Food Insecurity and Obesity
17 Health Effects and Cost of Obesity
17 Obesity and its Effects on Emotional and Cognitive Development
18 Long-Range Consequences of Obesity
18 The Impacts of Program Participation on Food Insecurity
18 Food Insecurity, Material Depression, and Child Health
19 Association Between Food Insecurity and Early Childhood Developmental Risk
19 Hospitalization
19 School-age and Adolescence
22 Cognitive Development
22 Case Study: Special Education
23 Socio-emotional and Behavioral Consequences
24 Lifetime Earnings
25 Direct Costs of Food Insecurity
25 Indirect Costs of Food Insecurity
25 Cost—Benefit Evaluations
26 Conclusion
We know how to fix the problem of childhood hunger,
and we have an opportunity now to build a prosperous
future for us all by doing that. Over the past century
Americans have built marvelous networks and systems
of infrastructure that are necessary to our economy
and quality of life. Through creativity, inventiveness,
ingenuity and hard work we have made our country a
model of success in many areas. For example, we have
built a national power grid, telecommunication systems,
water systems, transportation systems, and internet
systems that are peerless, to list just a few. But we have
not yet updated our food system to bring it fully in line
with 21st century knowledge and needs.
food to provide the solid foundation on which sharp
minds and strong bodies are built. As a result, the U.S.
economy has handicapped the minds and bodies of
much of its workforce and placed severe constraints
on its available pool of human capital.
In many ways the American food system reflects the
best of our economic and social accomplishments. The
U.S. food industry has achieved levels of productivity
and organization that reflect state-of-the-art
communication, transportation and management
technologies. Its integration with the global economy
involves feats of engineering and organization that
are unrivaled. But in other very important ways we
are still in the 1950s because we never completed the
infrastructure investments needed to make sure that
all American children always have enough healthy
This report summarizes results of research completed
by Children’s HealthWatch (formerly the Children’s
Sentinel Nutrition Assessment Program (C-SNAP)),
and by many other researchers, on the impacts of food
insecurity and hunger on children’s health, growth
and development. A large body of research literature,
amassed over the past two decades, shows clearly
that food insecurity and hunger together with other
correlates of poverty, can dramatically alter the
architecture of children’s brains, making it impossible
for them to fulfill their potential.
Fortunately, American business leaders are unlikely
to stand by idly while the hope and promise of a
prosperous and successful future for our children and
grandchildren slip away. Throughout our history we
have rallied to meet the demands of many serious
threats, and there are no compelling reasons why we
cannot meet the challenges posed by child hunger.
In this report we present the results of Children’s HealthWatch’s recent research on the associations of food
insecurity and hunger, as measured by the US Food Security Scale, with child health, growth and development.
In addition, we place these research results within the context of other research on food security and hunger over
the past ten years. Several important themes emerge from the research we describe. These include:
Child Hunger is a Health Problem
While every American is morally offended by the existence of childhood hunger, pediatricians and public health
professionals see the tragic effects of this unnecessary condition graphically imprinted on the bodies and minds
of children;
ungry children are sick more often, and more likely to have to be hospitalized (the costs
of which are passed along to the business community as insurance and tax burdens);
ungry children suffer growth impairment that precludes their reaching their full
physical potential,
ungry children incur developmental impairments that limit their physical, intellectual
and emotional development.
Child Hunger is an Educational Problem
ungry children ages 0-3 years cannot learn as much, as fast, or as well because chronic
undernutrition harms their cognitive development during this critical period of rapid brain growth,
actually changing the fundamental neurological architecture of the brain and central nervous system,
ungry children do more poorly in school and have lower academic achievement because they
are not well prepared for school and cannot concentrate,
ungry children have more social and behavioral problems because they feel bad, have less
energy for complex social interactions, and cannot adapt as effectively to environmental stresses.
Child Hunger is a Workforce
and Job Readiness Problem
orkers who experienced hunger
as children are not as well prepared
physically, mentally, emotionally or socially
to perform effectively in the contemporary
“The healthy development of all children benefits
all of society by providing a solid foundation for
economic productivity, responsible citizenship,
and strong communities.”
orkers who experienced hunger as
children create a workforce pool that
is less competitive, with lower levels
of educational and technical skills, and
seriously constrained human capital.
Child Hunger Leads to Greater Health Care Costs for
Families and Employers
• Short-term: hungry children have greater odds of being
hospitalized, and the average pediatric hospitalization costs
approximately $12,000.
• Long-term: results of chronic undernutrition that contribute
to high health care costs.
• Child hunger leads to greater absenteeism, presenteeism
and turnover in the work environment, all of which are costly
for employers. Child sick days are linked to parent employee
absences, for instance.
Child Hunger is Totally Preventable and
Unnecessary in the USA
• The federally-funded nutrition assistance infrastructure
works: nutrition assistance programs provide the first-line
defense against child hunger, if adequately funded.
Jack P. Shonkoff, MD, Director
Center on the Developing Child
Harvard University
• Good nutrition is just like a good antibiotic or vaccine in
preventing illness. The Supplemental Nutrition Assistance
Program—SNAP (formerly the Food Stamp Program), WIC,
the National School Lunch and Breakfast Programs, Child
and Adult Care Food Program, TEFAP and other public nutri­
tion assistance programs are good medicine, but the dose
is often not strong enough and the prescription is not for a
long enough time period. Many families cannot overcome
barriers to access these services which are crucial for health.
rivate food assistance programs guarantee that no child
falls through the cracks by buttressing, complementing and
supporting the public nutrition infrastructure—the Food
Bank network makes up the difference in dose required and
duration for which it is needed to cure the serious health
problem of child hunger.
orking together, in mutually supportive partnership, the
national public and private food assistance systems can
prevent and eradicate the unnecessary health problem of
childhood hunger, if we the people choose to do so.
octors strongly support this approach to “vaccinating” our children against childhood hunger and to treating
them effectively if and when this health problem does occur.
ixing the child hunger problem provides an opportunity to make strong, well-educated, healthy children into
an engine for growth in the American economy.
• America’s Business Leaders can play a central role in helping to make these investments happen.
Food is one of our most basic needs. Along with
oxygen, water, and regulated body temperature, it
is a basic necessity for human survival. But food is
much more than just nutrients. Food is at the core
of humans’ cultural and social beliefs about what it
means to nurture and be nurtured.
Food security—defined informally as access by all
people at all times to enough food for an active,
healthy life—is one of several conditions necessary
for a population to be healthy and well-nourished.1
Food insecurity, in turn, refers to limited or uncertain
availability of nutritionally adequate and safe foods,
or limited or uncertain ability to acquire food in socially
acceptable ways.2
Until the mid-1990s, lack of access to adequate food by
U.S. households due to constrained household financial
resources had been measured by questions assessing
“hunger,” “risk of hunger,” and “food insufficiency.” 3, 4,
5, 6, 7
In 1990, an expert working group of the American
Institute of Nutrition developed the following conceptual
definitions of food security, food insecurity and hunger,
which were published by the Life Sciences Research
Office (LSRO) of the Federation of American Societies
for Experimental Biology.8
ood Security: “Access by all people at all times to enough food for an active, healthy life. Food security
includes at a minimum: (1) the ready availability of nutritionally adequate and safe foods, and (2) an
assured ability to acquire acceptable foods in socially acceptable ways (e.g., without resorting to
emergency food supplies, scavenging, stealing, or other coping strategies).”
ood Insecurity: “Limited or uncertain availability of nutritionally adequate and safe foods or limited or
uncertain ability to acquire acceptable foods in socially acceptable ways.”
• Hunger: “The uneasy or painful sensation caused by a lack of food. The recurrent and involuntary lack
of access to food. Hunger may produce malnutrition over time…Hunger…is a potential, although not
necessary, consequence of food insecurity.”
These conceptual definitions were operationalized and a scale was developed to measure the operational
conditions at the household level in the U.S. population under guidance and sponsorship of the National Center
for Health Statistics and the U.S. Department of Agriculture in 1995-97. 9 Consisting of 18 questions, the U.S.
Food Security Scale (FSS) is administered annually by the Census Bureau in its Current Population Survey
(CPS) with results reported by USDA’s Economic Research Service (ERS). These repeated cycles of the FSS now
provide a time series of data on food security, food insecurity and hunger in the U.S. population for 1995-2007. 10
Relatively recently, a Children’s Food Security Scale (CFSS) consisting only of the eight child-referenced items
in the larger 18-item FSS has been validated by USDA/ERS. The CFSS can be scored and scaled to more directly
depict the food security status of children in a household. This child-referenced scale has also been shown to yield
higher prevalence of child hunger when administered separately than is obtained from the household-level FSS.11
The eighteen questions comprising the FSS are shown in Table 1, with the eight items that make up the CFFS in
the lower section. Thresholds for the various household and child food security categories are also indicated.
Additional changes were recently implemented by USDA/ERS in the way results from the Census Bureau’s
annual administration of the FSS are reported.12 These changes affect terminology used to label the most severe
level of deprivation measured by both the household and children’s scales by replacing the term “hunger” with
the blander (some would say euphemistic) term “very low food security.” 13 Because this change is relatively
recent, and not uniformly accepted by scientists, policymakers or advocates, we have elected to use the original
term “hunger” in this review when referring to the most severe category of food insecurity.
We also present material below that we hope will shed additional light on the meaning of the terms food
security, food insecurity and hunger, and how these conditions are related. A goal of that discussion is to
clarify what hunger is, and to provide readers with sufficient information about how it is measured to enable
reasoned decisions whether the term “hunger” is useful in describing the most severe levels of food insecurity.
Table 1: Questions Comprising the U.S. Food Security Scale with Child Food Security
Scale Questions in the Lower Section
1. “We worried whether our food would run out before we got money to buy more.”
Was that often, some times, or never true for you in the last 12 months?
Food Secure
2. “
The food that we bought just didn’t last and we didn’t have money to get more.”
Was that often, some-times, or never true for you in the last 12 months?
(0-2 items affirmed)
3. “ We couldn’t afford to eat balanced meals.”
Was that often, some times, or never true for you in the last 12 months?
4. In the last 12 months, did you or other adults in the household ever cut the size of
your meal or skip meals because there wasn’t enough money for food? (Yes/No)
5. (If yes to Question 4) How often did this happen—almost every month,
some months but not every month, or in only 1 or 2 months
6. In the last 12 months, did you ever eat less than you felt you should
because there wasn’t enough money for food? (Yes/No)
Household Food
Insecure Without
(3-7 items affirmed)
7. In the last 12 months, were you ever hungry, but didn’t eat, because you
couldn’t afford enough food? (Yes/No)
8. In the last 12 months, did you lose weight because you didn’t have
enough money for food? (Yes/No)
9. In the last 12 months, did you or other adults in your household ever not eat
for a whole day because there wasn’t enough money for food? (Yes/No)
10. ( If yes to Question 9) How often did this happen—almost every month,
some months but not every month, or in only 1 or 2 months?
Household Food
Insecure With Adult
Hunger Only
(8-10 items affirmed)
(Questions 11 – 18 are asked only if the household included children ages 0 -18 Yrs)
11. “ We relied on only a few kinds of low-cost food to feed our children because we
were running out of money to buy food.” Was that often, sometimes, or never true
for you in the last 12 months?
Child Marginally
Food Secure
12. “ We couldn’t feed our children a balanced meal, because we couldn’t afford that.”
Was that often, some-times, or never true for you in the last 12 months?
13. “The children were not eating enough because we just couldn’t afford enough
food.” Was that often, sometimes, or never true for you in the last 12 months?
Child Food Insecure
Without Hunger
14. In the last 12 months, did you ever cut the size of any of the children’s meals
because there wasn’t enough money for food? (Yes/No)
15. In the last 12 months, were the children ever hungry but you just couldn’t afford
more food? (Yes/No
16. In the last 12 months, did any of the children ever skip a meal because
there wasn’t enough money for food? (Yes/No)
Child Food Insecure
With Hunger
17. (If yes to Question 16) How often did this happen—almost every month,
some months but not every month, or in only 1 or 2 months?
18. In the last 12 months, did any of the children ever not eat for a whole day because
there wasn’t enough money for food? (Yes/No)
Relationship of Food Insecurity to Poverty
Food insecurity and hunger, as measured by the FSS, are specifically related to limited household resources.14
Thus, by definition they are referred to as “resource-constrained,” or “poverty-related” conditions. Financial
resources available to households can include income earned by household members and additional resources
derived from cash a and in-kind assistance provided by public and private safety-net programs, including public
and private food assistance programs, housing subsidies, and energy assistance.15,16,17,18
The official definition of poverty for the U.S. population uses
money income before taxes and does not include capital gains
or noncash benefits (such as public housing, Medicaid, and SNAP).
The definition is based roughly on historical estimates of the
portion of an average household’s income required to purchase a
“minimally nutritious diet” (about 30% in the early 1960s). Poverty
thresholds, set at three times the amount necessary to buy such a
diet, are amounts of money estimated by the federal government
to approximate statistical levels of necessity for families of different
size and composition (i.e., number of people in the household, and
number of children or elderly). Although the cost of living varies
widely from state to state and region to region, poverty thresholds
do not vary geographically. They are, however, updated annually
for inflation using the Consumer Price Index (CPI-U), a broad
national index of overall increases in aggregate consumer prices.b
The official poverty threshold for families of four people, two
adults and two children, was $21,027 in 2007. 19 All members of
a household with income below this level will be categorized as
being in poverty.
Both the definition of poverty and the poverty thresholds have been criticized on grounds that they do
not accurately reflect families true financial resources, nor the amount of money families actually need to
be economically self-sufficient.20 Estimates of minimum income levels required for families to achieve basic
economic self-sufficiency range around twice the federal poverty thresholds. 21
Based on the official poverty definitions, in 2007 (the latest year for which data are available), 37.3 million people
(12.5%) lived in households with incomes below the poverty thresholds in the U.S. Of these, 13.3 million were
children under age 18 years, and 5.1 million were children under 6 years of age. Subpopulations with highest
prevalence of poverty are people in female-headed households with no spouse present (28.3%), Blacks (24.5%),
Latinos (21.5%) and children under age 6 years (20.8%).22 From 2000 to 2004 the poverty rates for all major ethnic
groups increased steadily, though they declined slightly from 2005–2006 and increased in 2007 (Figure 1).
Most federal sources of cash assistance available to families and children are managed by agencies within the Department of Health
and Human Services. Descriptions of these financial assistance programs can be found at
viewed June 25, 2007.
Moreover, though an average U.S. family currently spends only about 12% of its total annual expenditures on food, implying a poverty
threshold nearer eight (100% ÷ 12%) times the cost of a minimally nutritious diet instead of three times, this “multiplier” has not been
updated since its conception in the early 1960s. See “The Development of the Orshansky Thresholds and Their Subsequent History as the
Official U.S. Poverty Measure,” by Gordon M. Fisher (1992), at viewed
July 13, 2007.
Figure 1: Proportion of U.S. Families with Incomes
Below Poverty by Race/Ethnicity, 1999-2007*
All Races
Non-Hispanic Black
Non-Hispanic White
* Includes households with and without children.
Source: U.S. Census Bureau Current Population Survey, various years.
Though the populations affected by poverty and food insecurity overlap, they are not identical. Not all poor
people are food insecure and the risk of food insecurity extends to people living above the federal poverty
level.23 In 2007, the latest year for which data are available, 36.2 million people in the U.S. (12.2%) lived in foodinsecure households, 24.3 million in households without hunger and 11.9 million with hunger (Figure 2). Of the 36.2
million food-insecure people in the U.S. in 2007, 12.4 million were children under 18 years of age. As with poverty,
subpopulations with the highest prevalence of household food insecurity are Blacks (22.0%), Latinos (22.3%),
people in households with children under 6 years of age (17.7%), and single-mother households (30.4%).24
In 2007, 39.9% of all people in the U.S. with incomes below the poverty thresholds were food insecure. Of all
people with incomes equal to or above the poverty threshold but below 130% of poverty (gross income cutoff
for SNAP in most states), 30.3% were food insecure, while 21.3% of all people with incomes equal to or above
130% but below 185% of poverty (gross income cutoff for WIC) were food insecure. Only 5.7% of all people with
incomes at or above 185% of poverty were food insecure. These prevalence estimates suggest that for some
families “safety net” programs, such as the national food assistance programs, housing and energy subsidies, and
in kind contributions from relatives, friends, food pantries, or other charitable organizations, not included in the
federal poverty calculations, may partly decrease the risk of food insecurity. Families that do not receive public
benefits for which they are income eligible (either because of bureaucratic barriers or because the programs
are not entitlements and are insufficiently funded to reach all who are eligible) may be more likely to be food
insecure. Moreover, many families whose incomes exceed the eligibility cut-off for these programs may still be
unable to avoid food insecurity without assistance if the costs of competing needs such as energy or housing are
overwhelming. From 1999 to 2004 the prevalence of food insecurity increased steadily for all major race/ethnic
groups, but declined in 2005 and increased among Hispanic households in 2006, and among all three groups in
2007 (Figure 2) on next page.
Figure 2: Proportion of U.S. Households that are
Food Insecure by Race/Ethnicity: 1999-2005*
All Races
Non-Hispanic Black
Non-Hispanic White
* Includes households with and without children.
Source: USDA/ERS Food Security in the U.S., various years.
Averaging data over the years 2005–2007, USDA/ERS calculated state-level estimates of the proportion of
households in each state that was food insecure over this period. The lowest state-level household food insecurity
prevalence was 6.5% in North Dakota; the highest was 17.4% in Mississippi. In 34 states more than 10% of all
households were food insecure. The prevalence of food insecurity with hunger was lowest in North Dakota
at 2.2% and highest in Mississippi at 7.0%. Eleven states had average prevalence rates of food insecurity with
hunger of 5% or higher over this period.25
What are food security, food insecurity, and hunger, and how are they related?
Food Security: Food security is the condition of having regular access to enough nutritious food for a healthy
life. In the United States, the concept of food security is assessed using the U.S. Food Security Scale, an official,
government-sponsored evaluation instrument that captures food security at the household level. The Census
Bureau administers the U.S. Food Security Scale annually in its national Current Population Survey, and the USDA
Economic Research Service analyzes the data and publishes a report on Food Security in the U.S each year.
Food Insecurity: Food insecurity is the condition of not having regular access to enough nutritious food for a
healthy life. High and low levels of food insecurity are differentiated based on the duration and severity of food
insecure periods. In the U.S., having access to nutritious food requires that the food be physically present in
the local food system (e.g. supermarkets; other food stores; markets; restaurants; and food vendors), and that
households have sufficient financial resources to purchase it. Thus poverty is the major proximal cause of food
insecurity in the U.S.
The Food Insecurity Continuum:
n the least severe end of the spectrum, food insecurity manifests as household members’ worries or
concerns about the foods they can obtain, and as adjustments to household food management, including
reductions in diet quality through the purchase of less-expensive foods. There is generally little or no
reduction in the quantity of household members’ food intake at this level of severity, but micro-nutrient
deficiencies are common.
s the severity of food insecurity increases, adults in the household often reduce the quantity of their food
intake, to such an extent that they repeatedly experience the physical sensation of hunger. Because adults
tend to ration their food as much as possible to shield the children in the household from the effects of
food insecurity, children do not generally experience hunger at this level of insecurity, though their diets
tend to be extremely poor in nutrients.
• In the most severe range of food insecurity, caretakers are forced to frequently reduce children’s
food intake to such an extent that the children experience the physical sensation of hunger. Adults, in
households both with and without children, consistently experience more extensive reductions in food
intake at this stage.
Hunger: Hunger, defined as the uneasy or painful sensations caused by a lack of food, occurs when food intake
is reduced below normal levels. Hunger is both a motivation to seek food and an undesirable consequence of lack
of food. Though experienced by everyone episodically, hunger becomes a social problem when the means of
satisfying the drive to seek food, and of relieving the uncomfortable or painful sensations that accompany hunger,
are not available or accessible due to lack of resources. Relevant questions about child hunger include:
• If an adult respondent to the FSS answers “Yes” to any of the following three questions, would you say the
children in the household experienced hunger?
1. In the last 12 months, did you ever cut the size of any of the children’s meals because there wasn’t
enough money for food? (Yes/No)
2.In the last 12 months, were the children ever hungry but you just couldn’t afford more food? (Yes/No)
3. In the last 12 months, did any of the children ever skip a meal because there wasn’t enough money for
food? (Yes/No)
4. In the last 12 months, did any of the children ever not eat for a whole day because there wasn’t enough
money for food? (Yes/No)
Do Food Insecurity and Hunger Matter?
Food insecurity and hunger are intrinsically undesirable and harmful,
that is they are undesirable and harmful in and of themselves. But
even more important, for this report especially, they also are harmful
to the human capital formation and accumulation of those who
experience them. That harm ultimately leads to higher costs of
several kinds, lost productivity, and constraints on success among
American businesses.
Child food insecurity and hunger are especially harmful during the
first 3 years of life, because this is the sensitive period in which
the foundation is being laid that will support human capital formation
throughout the school years, and on into adulthood. The kinds of
nutrition, care, stimulation and love children receive during these
critical first three years of life determine the architecture of the
brain and central nervous system. These structures form the basic
foundation on which each child’s future is constructed.
Children’s school readiness is built on growth, development
and experiences during the first three years of life. Success in
kindergarten builds on readiness achieved in years 0-3; success
in grade school builds on growth, development and learning in
pre-school and kindergarten, and so on.
“So the sobering message here
is that if children don’t have
the right experiences during
these sensitive periods for the
development of a variety of
skills, including many cognitive
and language capacities, that’s
a burden that those kids are
going to carry; the sensitive
period is over, and it’s going
to be harder for them. Their
architecture is not as well
developed in their brain as
it would have been if they
had the right experiences
during the sensitive period.
That’s the sobering message.”
Jack P. Shonkoff, MD
Harvard University School
of Public Health
Recent research has shown that each of these stages involves important human capital formation, and that
each builds on the human capital accumulated during the previous stage. And while each stage is important,
none is more important than the years 0-3. Those years, and the prenatal period, set the stage for the rest of
a person’s life, and they are the most vulnerable to stress and damage that can result from food insecurity and
hunger. In the following section we summarize the basics of human capital theory and suggest that it provides a
useful framework for considering why business leaders should care about child hunger.
Human Capital Theory
Human capital theory, developed and articulated by Gary Becker in the early 1960s, is a very useful framework
for considering the economic consequences of childhood food insecurity.26 Elaborated by a host of economists
since, the theory envisions the unique capabilities and expertise of individuals as a stock of “human capital,” useful
to individuals and firms as an input into desirable work and activity. A person’s human capital stock is a primary
determinant of the kinds of employment they can successfully compete for, their consequent earning capacity, and
lifetime earnings.
Initial Human Capital Endowment
Every individual is born with a particular human capital endowment comprised of their genetic material as expressed
in interaction with the environments in which they grow and develop. This interaction begins during the prenatal
period, when development is heavily influenced by maternal nutrition, stress, and healthcare, among other factors.
From conception until death, each person undergoes a continuous process of human capital formation and
destruction. Early developmental periods, especially the periods of rapid brain and central nervous system (CNS)
development during the first three years of life, are critical in determining a person’s potential for human capital
formation later in life. Circumstances that impair or interfere with health, growth and development during these
periods can have lasting negative impacts on human capital formation throughout life.
The Role of Education in Human Capital Formation
In Becker’s formulation of human capital theory, education is the primary vehicle for human capital formation.
Other forms of human capital formation include training (on and off the job), experience (on and off the job),
investments in health, outreach and extension programs, life experience,
migration, and the individual’s search for understanding.
Health and the Enhancement, Preservation and Destruction of Human Capital
Human capital is a stock, in that it accumulates rather than flows (as income does). However, this particular stock
is very dynamic. It can be increased by additional education, training, investments in health, improved nutrition,
and adoption of a healthier lifestyle. Similarly, it can be diminished by injury and trauma, disease and illness,
malnutrition, risky behavior, and unhealthy lifestyles.27
Factors influencing child health can both impair human capital formation and diminish human capital already
formed. Examples of liabilities to human capital development in early childhood include:
• Malnutrition;
• Disease and illness;
• Injury and trauma;
• Inadequate or non-existent healthcare;
• Exposure to environmental toxins;
• Exposure to and/or victimization by violence;
• Chronic illness; and
• Familial stress.
Many risks to children’s human capital are correlates of poverty and food insecurity.
Households as Producers
Household production theory, an elaboration of human capital theory, views each family as a production unit that
uses inputs to produce things the household needs and wants for its collective satisfaction, utility or well-being.
Each household combines resources, such as purchased goods, household labor, time, energy, and human capital,
to produce things for consumption by family members.
Household Production of Human Capital
Human capital itself is a very important output produced by families via the household production process. Parents
combine their human capital with other inputs (time, attention, books, toys, food, etc.) using care and interaction
to nurture critical human capital formation in their children. Taking education as an example, children in turn build
gradually upon their sum total of human capital to accumulate the stock necessary for school readiness: capacity
for future learning and successful physical, social, and psychological adaptation to new environments.
These capacities are heavily determined by the extent and quality of parent-child interactions and the level of
stimulation in the home environment (household inputs). Early deficits in household inputs can diminish human
capital in young children, predisposing them to failure in school and diminishing their potential for forming and
expressing future human capital as successful, productive members of the workforce and society.28
Food Security as Human Capital and Household Production Input
Food security, like health, is itself an important form of human
capital, and a critical input into household production of other
forms of human capital such as good health, cognitive, psychological
and physical development and growth, self-confidence, social skills,
and school readiness. Food secure families can access enough
nutritious food to promote healthy growth and development, or
human capital formation, in their children. Food insecurity, on the
other hand, means a shortage or absence of inputs that are essential
to the optimal formation of human capital in children.
Beyond impairments caused by inadequate food and nutrients,
children in food insecure households also suffer ill effects due to
the family stress that frequently accompanies, and is often caused
by, food insecurity. Parental physical and mental health problems
associated with food insecurity impair parent-child interaction, limit
parents’ elaboration of children’s first efforts at speech, reduce
quantity and quality of stimulation available in the home environment,
and interfere with children’s optimum human capital formation.
“The current economic and
housing crises have made it
absolutely imperative that we
invest in young children today.
To have the economy we want
in the future, we must invest
in children now to help them
become productive, successful
adults. In particular, research
shows that children are likely
to pay a steep price for the
nation’s housing crisis, because
of the disruption it causes in
their lives and their educational
Robert Dugger,
Managing Director,
Toudor Investment Corporation.
Advisory Board Chair,
Partnership for America’s
Economic Success
Food insecurity influences health and development through its impacts on nutrition and as a component of overall
family stress. The condition of food insecurity includes both inadequate quantities and inadequate quality of
nutrients available. At less severe levels of food insecurity, household food managers (usually mothers) trade off food
quality for quantity to prevent household members, especially children, from feeling persistently hungry.29 Several
kinds of social infrastructures can influence the relationships between food insecurity and child health, growth and
development by helping to prevent food insecurity from occurring, or by moderating its effects once it occurs.
Poor nutrition, and by extension food insecurity, has been shown to influence health and well-being throughout
the life cycle, from the prenatal period on into elder years. 30, 31, 32, 33, 34, 35, 36 In addition, effects of food insecurity on
adults in households with children can adversely impact those children in a variety of ways, including diminution
of parents’ energy for providing care and developmental stimulation. Parental (especially maternal) depression
has been associated with food insecurity, and in many contexts, not limited to those involving food insecurity,
such depression has been linked with adverse impacts on parenting, parent-child interaction and attachment,
child growth, development, health and well-bring.38, 39, 40, 41
The Prenatal and Neonatal Periods
Adequate prenatal nutrition is critical for normal development of the fetal body and brain. Though a large volume
of research has confirmed the importance of nutrition during the prenatal and neonatal periods,42,43,44,45 far fewer
studies have specifically addressed the role of food security per se for this part of the life cycle. Food insecurity
has been associated with low birth weight deliveries,46 and with a variety of psychosocial risk factors in moderate
to high-risk pregnancies with observable dose-response relationships (increasingly higher psychosocial risks with
increasing severity of food insecurity).47 Evidence on the influence of food insecurity in prenatal development remains
largely indirect, deriving from the large body of evidence for the critical role of healthful nutrition during this period.
It is noteworthy that a large number of recent studies have examined prenatal nutrition and care within a broader
scope that includes birth spacing and nutrition and care between births.48, 49, 50, 51, 52, 53 Motivated in part by persistently
high rates of low birth weight and preterm births in some U.S. subpopulations, a growing recognition of the limits
of prenatal care alone in reducing these problems has emerged, with increasing attention being paid to precon­
ception and internatal care.54 Amid this emerging view of maternal health are expressions of concern about the
effects of food insecurity on nutrition and health during the internatal period.55 Of particular concern is the risk
of food insecure mothers entering pregnancy with insufficient iron stores and with diets inadequate in folate.
Poor iron and folic acid status have been linked to preterm births and fetal growth retardation respectively. 56
Prematurity and intrauterine growth retardation are critical indicators of medical and developmental risks which
not only impact children’s short-term well being but extend into adulthood where they have been linked recently
to obesity, adult onset diabetes, and risk of cardiac disease.57 A woman’s diet inadequate in folate in the pericon­
ceptual period has also been clearly associated with neural tube defects and possibly with other birth defects.58
For low-income mothers, especially Black, Latino and single mothers, food insecurity is a highly prevalent risk
factor generally, including during internatal periods.59, 60
Low Birthweight
Overall fetal growth is significantly influenced by maternal nutrient intake. Birthweight, in turn, is strongly
correlated with perinatal and infant mortality, with low birthweight heightening the risk of mortality.61
Low birthweight also has a long-term impact upon infant health and growth trajectories. Infants who are born
small for gestational age remain shorter and lighter and have smaller head circumferences than their peers
through early childhood.62 Low birthweight is associated with poor long-term outcomes in areas including:
dult Height: A 10% increase in birthweight results in between .5 and .75 cm increase in adult height.
Height is important as, in many cases, it is a proxy for social and health conditions early in life. Shorter
stature correlates with shorter average lifespan, and it is believed that the underlying cause for this
correlation is poor early-life conditions, including inadequate nutrition and infection. Shorter adult stature
also correlates with lower adult socioeconomic status (SES)
and education, which in turn influence earnings and type of employment.63
• IQ at 18 years of Age: Low birthweight is associated with lower age 18 IQ.64
ducational Attainment: A 10% increase in birthweight increases a child’s odds of graduating from high
dult Earnings: Increased educational attainment increases an individual’s expected earnings as an adult.66
Treating low birthweight infants is a costly endeavor. The average aggregate cost of caring for a very low birth
weight infant over his or her first year of life was $59,730.67 The variations of cost can be seen in Figure 3 below.
Figure 3: Average Cost of Caring for Very Low Birthweight Infants
During Their First Year of Life.68
All Infants (887)
Infants who died
within one day of
birth (205)
Infants who died
during remainder of
initial hospitalization
Infants surviving initial
hospitalization who
died in first year of life
Infants who survived
first year of life (565)
Infants who survive their initial hospitalization but die before their first birthday are the most expensive to treat
($112,120 on average).69 Infants surviving to age one cost an average of $76,850, with the cost difference being
driven largely by the cost of rehospitalization ($5,290 per infant). Infants who do not survive their initial hospital­
ization cost an average of $6,310 (those surviving one day) or $58,800 (those dying during the remainder of initial
hospitalization).70 The cost-effectiveness of treatments varies by the infant’s birthweight, with the heavier infants
having the best chance of survival, needing the least intervention, and therefore costing the least. This can be
seen in Figure 4 below.
Figure 4: Cost-Effectiveness of Treating Very Low Birthweight
Infants Improves with Higher Birthweights.71
Under 750g
(39 survivors out of
214 total)
750 – 999g
(109 survivors out of
191 total)
1,000 – 1,249g
(174 survivors out of
206 total)
1,250 – 1,499g
(243 survivors out of
276 total)
Note: Cost are in constant 1987 dollars, rounded to the nearest hundred
Preterm birth also has a negative impact on the employment behavior of the parents. Mothers of preterm or low
birthweight babies took a longer maternity leave, reduced their hours at work, or left the workforce altogether
to care for their child.72 This decrease in productivity was average associated with a decrease in family income
of 32%.73 In a 1996 to 2001 study done in Toronto, researchers found that mothers from the lowest-income
neighborhoods were 25% more likely to have a preterm birth than mothers in the richest neighborhoods, and
53% more likely to have an underweight baby at full-term.74 As a result, the 32% decrease in family income due
to loss of productivity from caring for a preterm or low birthweight baby creates a proportionally greater
decrease in low income families who are at highest risk for preterm or low birthweight babies.
Beyond general growth delay, maternal undernutrition has significant effects on specific physical systems in
the developing fetus. Severe food insecurity late in the gestational period impairs fetal body, organ, and cellular
growth. The adrenals, placenta, and liver are most affected by maternal undernutrition; women who begin
their pregnancies underweight and experience low pregnancy weight gain tend to give birth to children with
disproportionately low weights for some body organs and small adrenal and liver cells, the classic physiological
picture of undernutrition.75
Early Childhood: Ages 0-3 Years
A relatively large number of studies have examined associations between food insecurity and child health and
development in this age group, many conducted by Children’s HealthWatch.c An ongoing multi-site pediatric
clinical research program, Children’s HealthWatch has conducted household-level surveys and medical record
audits at seven central-city medical centers, including acute and primary care clinics (Baltimore, MD; Minneapolis,
MN; Philadelphia, PA and Washington, DC) and hospital emergency departments (Boston, MA; Little Rock, AR;
and Los Angeles, CA) since 1998.d Primary adult caregivers accompanying children 0 to 36 months old seeking
care are interviewed by trained interviewers in private settings during waiting periods.e Children’s weight and,
if possible, length are recorded at the time of the interview.
The Children’s HealthWatch survey instrument is composed of questions on household characteristics, children’s
health and hospitalization history, maternal health, maternal depressive symptoms, participation in federal
assistance programs, energy insecurity, and changes in benefit levels. In addition, the Children’s HealthWatch
interview includes the U.S. Food Security Scale,76, 77, 78 and recent cycles of data collection since July 2004 have
added the PEDS (Parents’ Evaluation of Developmental Status—a well-validated and reliable standardized
instrument that meets the American Academy of Pediatrics standards for developmental screening).79 These
studies suggest complex relationships between food insecurity and participation of families with young children
in public income maintenance and nutrition programs. They also indicate similarly complex relationships between
participating in these programs and food insecurity, health, growth, and development of young children.
Food Insecurity and Adverse Health Outcomes in Young Children
By 2003 a large body of research literature had confirmed a range of adverse health and development outcomes
associated with malnutrition in young children, and a few had found food insufficiency (a pre-cursor to the
food security measures), hunger and risk of hunger related to poor health in children (ages
increase in the odds of fair/poor health above the odds when only HFI was present (from 1.51 to 2.00). Though
the presence of CFI in addition to HFI resulted in an increase in odds of hospitalization from 1.19 to 1.24, this
increment was not statistically significant.94
Participation in the SNAP (formerly the Food Stamp Program) modified the effects of food insecurity on child
health status (odds of fair/poor health), reducing, but not eliminating them. Children in FSP-participating
households that were HFI only had adjusted odds of fair/poor health 24% lower than those in similar non-FSP
households, while children in FSP-participating households that were H&CFI had adjusted odds of fair/poor
health 42% lower than those in non-FSP households.95
These results, like previous ones, indicate that the relationship between food insecurity and the health status
of very young children is such that the adverse effects of food insecurity worsen as its severityincreases. They
also suggest that SNAP benefits, like a therapeutic drug prescribed in inadequate doses, appear to attenuate
but not fully reverse this association.
Child Food Insecurity and Iron Deficiency
Iron deficiency, and iron deficiency anemia (IDA), are the most prevalent nutritional deficiencies in the U.S. and
worldwide.96, 97 Iron deficiency in early life has been linked to concurrent and persistent deficits in cognition,
attention, and behavior even after treatment. Several recent studies have reported a prevalence of IDA in
children up to 18% in some high-risk subpopulations in the U.S.98, 99, 100, 101 One study found that joint or separate
participation in the WIC and SNAP reduced the risk of iron deficiency. The link between these child nutrition
programs and iron deficiency confirms a recent Children’s HealthWatch study that examined associations
between child food insecurity (CFI) and IDA in children ages 6-36 months.103 Infants ages 10 mcg/dl) were excluded from this study. In logistic regressions adjusted for a range
of possible confounders, food insecure children had adjusted odds of having IDA 140% greater than food secure
children. Only household food insecurity, and not child food insecurity, was examined in this study.104
IDA is a troublesomely common problem among at-risk pediatric populations. The Pediatric Nutrition
Surveillance System (PedsNSS), a national program run by the Centers for Disease Control and Prevention,
found a 14% prevalence of anemia in 2001 among children under 5 years old in its sample comprised mostly of
low-income, nutritionally at-risk children.105 In severe cases, hospitalization is required; in 2003, over 100 children
under the age of 5 were hospitalized for dietary iron-deficiency anemia, at an average cost of $5,573 per child. 106
Research on food insecurity and overweight has, in the past, mostly focused on adults and school-aged children.107
However, a growing body of research about young children demonstrates a strong correlation between early food
insecurity and later overweight and obesity. The pathways through which this correlation acts are not yet fully
defined, but thus far appear to involve quality and quantity of food consumed; health and feeding practices; and
caretaker depression.
Connecting Food Insecurity and Obesity
Families with children, especially those with young children, are the group most likely to be food insecure.108 In
turn, children whose families are food insecure are more likely to be at risk of overweight (>85% weight-for-age) or
obesity as compared to children whose families are food secure.109 Children experiencing child food insecurity, the
most severe level of food insecurity, are at even greater risk of being overweight, and this trend has definitively
begun by the preschool years (ages 3-5).
Research using the measure of ‘food insufficiency’, which captures the equivalent of severe food insecurity,
found that if a family with young children had experienced food insufficiency at any point during the child’s
toddler years, the child was 3.4 times more likely to be obese at 4.5 years old.110 This increase in risk was greater
than the 2.5-fold risk increase associated with having an overweight or obese parent. Low birthweight (LBW)
(4000g) who
experienced family food insufficiency had odds 5.7 times higher.111
Health Effects and Costs of Obesity
Obesity is highly correlated with many health problems, among them cardiovascular disease, hypertension, diabetes,
and joint degeneration.112, 113, 114 Disturbingly, these problems of middle-age and older adults are being found at
younger and younger ages. A recent study in Georgia found that even adolescents with mid-range body mass
displayed increases in blood pressure, arterial stiffness, and other signs of cardiovascular trouble.115 In another
study, overweight adolescents had more Medicaid claims for diabetes, asthma and respiratory problems than
normal weight adolescents.116 The total estimated medical cost in the United States for obesity-related disease
management among 6-17 year old children reached $127 million in 2003, and continues to rise along with the
prevalence of overweight and obesity within this age group.117 Beyond immediate healthcare costs, the early onset
of health problems associated with obesity shortens the
lifespan of affected individuals, contributes to increased
rates of morbidity, and influences their lifetime earning
potential. Unfortunately, though overweight and obesity
are documented in toddlers through school-age, little
research has been conducted on the consequences and
costs of obesity for children younger than six.
Obesity and its Effects on Emotional and
Cognitive Development
In addition to physical consequences, obesity has
a substantial negative impact on the emotional and
cognitive well-being of young children. Overweight
and obese children are often stigmatized by their
WITH 18.9% OF ALL CHILDREN IN HOUSEpeers, and stigmatization can profoundly influence
their psychological and social development.118 Young
children who are overweight or obese typically
become overweight adolescents, and body image is
often a major focus at this time of life, leading to poor
self-esteem, emotional health problems and issues with
social adjustment among this group.119 One study using the National Longitudinal Study of Adolescent Health
found that among children 12 to 14 years-old, overweight and obese children were significantly more likely to be
depressed, report low self-esteem, and have poor school/social functioning compared to normal weight children.120
Among obese adolescents, lower levels of self-esteem have been associated with increased rates of sadness,
loneliness, nervousness, smoking, and alcohol consumption.121 One study of adolescents found that obese children
were more likely to isolate themselves socially and report serious emotional problems. These problems in turn led
to direct loss of human capital through:
uicide: Obese girls were nearly twice as likely to have attempted suicide as their
non-obese peers.122
cademic underachievement: Obese adolescents were more likely to perceive themselves
as below average students, and boys were twice as likely to expect to quit school.123
Long-Range Consequences of Obesity
If overweight and obese children are unable to reduce their Body Mass Index (BMI) as they grow older, they face
an adulthood where the costs of obesity can include diminished employment
opportunities and reduced incomes.
• A study of former welfare recipients found that morbidly obese White women trying to transition from
welfare to work were less likely to find employment, spent more time receiving cash welfare, and had lower
monthly earnings than similar non-obese women.124
nother study by the same author found that among White females, a difference in weight of about 65
pounds was associated with a 9-percent difference in wages.125 This effect of weight on earnings is similar
in magnitude to the effect of 1.5 years of education, or 3 years of work experience, on wages earned.
third study found that among adults, a one-point increase in BMI over time was associated with a $1,000
decrease in net worth on average, holding other factors such as income constant.126 One major reason for
this association was that overweight and obese adults tended to leave school earlier than their peers.
Obesity is thus an offshoot of food insecurity that has lasting consequences for the long-term
economic productivity and security of individuals.
Food Insecurity, Maternal Depression, and Child Health
Maternal depression is strongly related to child development in a variety of ways, including reduced ability to
provide needed care, impaired mother-child interaction and attachment, and child neglect and abuse.127, 128, 129, 130, 131,
Several recent studies have found associations between food insecurity and maternal depression.133, 134
A recent Children’s HealthWatch study examined associations among mothers’ positive depressive symptoms
(PDS), food insecurity and changes in benefits from federal assistance programs.135 Using a subsample of 5,306
mother-child dyads seen at three of the Children’s HealthWatch sites, we found that mothers with PDS had odds
of reporting household food insecurity 169% greater, fair/poor child health 58% greater, and child hospitalizations
20% greater than mothers without PDS, after adjusting for possible confounders. In addition, controlling for the
same covariates, mothers with PDS had odds of reporting decreased welfare support 52% greater, and odds of
reporting loss of SNAP benefits 56% greater than mothers without PDS.136
These results suggest that maternal depression may be an indirect pathway by which household food insecurity
exerts negative influence on child health and development. It is not possible to determine the direction of causality
from these results, nor to rule out the possibility of some amount of dual causality. Additional longitudinal research
is needed to determine whether and under what circumstances maternal depression temporally precedes food
insecurity, and vice versa.
The Impacts of Program Participation on Food Insecurity
In a study examining associations between participation in the Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC) and indicators of underweight, overweight, length, child’s health status,
and food security in children ages ≤12 months, Children’s HealthWatch researchers found that infants that did
not receive WIC benefits because of access problems were more likely to be underweight, short, and perceived
as having fair/poor health, compared with WIC recipients, after adjusting for possible confounders.137 Though
these two groups did not differ significantly on food security status after adjusting for covariates, children in
both were more likely to be food insecure than children whose caregivers did not perceive a need for WIC. These
results supported findings from other research indicating that low-income infants ≤12 months of age benefit from
participation in the WIC program. 138, 139, 140
Another Children’s HealthWatch study examining the relationships between receiving housing subsidies and
nutritional and health status among low-income food-insecure children ages
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