key: cord-325138-riu4jdc2
authors: Hassink, Sandra G.; Fairbrother, Gerry
title: Obesity and Hunger Threaten the Foundations of Child Health
date: 2020-08-13
journal: Acad Pediatr
DOI: 10.1016/j.acap.2020.08.010
sha: 
doc_id: 325138
cord_uid: riu4jdc2

nan

On the face of it, childhood obesity and child hunger seem like very different problems. However a deeper look reveals that the root causes of each are intertwined and overlapping. Both are conditions of poverty, both result from lack of nutritious food, and both lead to disease and affect large numbers of children. Childhood obesity and food insecurity can co-occur, and in some children food insecurity is associated with an increased risk of obesity. 1, 2 Further, and especially important now: both obesity and food insecurity confer increased risk from COVID-19 and are potentially exacerbated by the stress of food scarcity during the pandemic.

Food insecurity and obesity in children co-exist with childhood poverty and both are most prevalent in the poorest regions. 3,4,5, In 2017, nearly 35% of households with children and incomes below 185% of the federal poverty level, were food insecure compared to <6% among more affluent households. 4 A study of 68 school districts in Massachusetts found an independent relationship between community income status and rates of childhood overweight/obesity indicating that the economic status of a family may be more important than race and ethnicity in childhood obesity prevalence. 6 Common systemic factors that may lead to both obesity and food insecurity in economically disadvantaged populations include, poorer access to and higher cost of nutritious foods and a shared food system that advantages lower-cost, high energy dense foods. 7 Not surprisingly given the connection with poverty, food insecurity rates vary with economic conditions, with greater food insecurity in economic downturns. In the Great Recession, food insecurity in households with children jumped from 15.8% in December 2007 to a high of 21.3% in June of 2009. By 2018, pre COVID-19, the overall rate dropped to13.9%. 8 With the sharply enhanced and continuing rise in unemployment due to COVID-19 restrictions, food insecurity has increased and may even exceed levels seen in the Great Recession. 9

Both obesity and food insecurity result from lack of nutritious food Childhood obesity and food insecurity coexist but their relationship is complex. No consistent theories have yet emerged to explain these relationships. However, we know that availability of nutritious food is key to reducing both obesity and food insecurity in children.

The underlying causes of food insecurity and obesity have to do with our inability to ensure that all children have a daily food intake that "contains an appropriate density of nutrients, is sufficiently diverse that it supplies adequate but not excessive amounts of nutrition, is palatable and culturally acceptable, affordable and available year round and overall supports normal growth and development". 10 Food insecurity may compromise nutritional quality with the purchase of cheaper, more energy dense foods. 11 Findings suggest prices of fruits and vegetables and fast food may have some influence on consumption in certain subgroups, such as children and low income families. 12, 13 In a longitudinal study, children's weight was positively related to fruit and vegetable prices with children in poverty and children at risk for overweight the most price sensitive. 14 Affordable food pricing for nutritious foods should be considered when policy makers look at economic strategies to drive purchasing. 13 Both Obesity and Food Insecurity lead to disease.

Both obesity and food insecurity negatively affect child and later adult health and wellbeing.

Children in food-insecure households have worse general health and are more likely to have asthma, chronic skin conditions and depressive symptoms, colds, stomach problems, 15 and stress. 16, 17 Compromise in immune functioning associated with food insecurity may also compromise overall child health status. 18 In addition, children who are food insecure have a greater risk of hospitalization, and food-insecure households have higher mean health care expenditures than food-secure households. 19 Childhood obesity is a multisystem chronic disease and children with obesity are more likely to have high blood pressure, non-alcoholic fatty liver disease, asthma, 20 type 2 diabetes mellitus, polycystic ovary syndrome, sleep apnea, musculoskeletal disorders, and psychological problems. 21 These underlying disease states make children more vulnerable to adverse outcomes if they do contract COVID-19.

Cardiovascular disease and type 2 diabetes in adulthood are linked to obesity in childhood. 22, 23 Childhood obesity results in increased healthcare costs from prescription drugs, emergency room visits and outpatient expenditures. 24 It is important to appreciate that access to healthy food is not only crucial to prevention of childhood obesity and hunger, it also constitutes treatment for childhood obesity 25 and the health effects of hunger. 26 Withholding healthy food from children with obesity and obesity-related comorbidities is essentially withholding treatment for their disease.

Both obesity and food insecurity affect large numbers of children. In the United States in 2015-2016 the prevalence rates for childhood obesity were 13.9% in children 2-5 yr., 18.4% in children [6] [7] [8] [9] [10] [11] yr., and 20.6% in adolescents 12-19 yrs. with an overall prevalence of 18.5 %. 27 In 2018, 13.9% of households with children under 18 years were food insecure. If these households were headed by a single man or woman, rates of food insecurity increased to 15.9% and 27.8% respectively. 28 Childhood obesity rates have progressed steadily upward from 5-6% in the 1970s to 18.5% in 2016. 27 In contrast, food insecurity rates vary with economic conditions as described earlier.

Not surprisingly, given the level of food insecurity among low-income households, there are a number of federal programs that provide food for low-income children and families-15 in the US Department of Agriculture alone. 29 Specific federal programs which "serve as critical supports for the physical and mental health and academic competence of children " are SNAP, WIC, Child and Adult Care Food Program, School breakfast and lunch program, and the Summer Food Service Program 26 Food programs like these are opportunities to provide healthy food for children most at risk for food insecurity and obesity. These programs serve a critical role, but they are lacking in important ways, primarily in having inadequate levels of funding and in having requirements that make it difficult for families to access the benefit.

Both SNAP and WIC are important sources of nutrition for children and infants. SNAP is the largest federal nutrition assistance program. It provides benefits to eligible low-income individuals and families via an Electronic Benefits Transfer card. This card can be used like a debit card to purchase eligible food in authorized retail food stores. WIC provides federal grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk. 29, 30 In fiscal year 2017, SNAP served an average of 8.6 million households with children each month, representing 42 % of all SNAP households. 31 Since the 2008 recession SNAP caseloads have declined with 45 states having fewer SNAP recipients in 2018 than in 2013. In 10 states by 2018 SNAP participation had fallen to pre-recession levels and was expected drop even further because of the improving economy 32 Instead, in response to widespread unemployment, school and child care closures due to COVID-19 SNAP enrollment is expected to increase for the foreseeable future. 33 SNAP is even more crucial in the economic downturn because increased access to and participation in SNAP reduces the rise in food insecurity for children 34 and risk of obesity in children under 3. 35 Households that experience reduction of SNAP benefits have increased household food insecurity, child food insecurity, housing instability and energy insecurity. 36 In contrast, WIC participation initially dropped with the onset of the COVID pandemic due to in person visit requirements, closure of WIC offices and enrollment timing limitations. 37 These added to known barriers to WIC participation which include 1) eligible families not knowing they can apply 2) at risk families not perceiving a need for the program 38 3) fears that WIC participation may threaten immigration status 39 4) fear of stigma from receiving government aid 40 5) difficulty with transportation 6) need to miss work 7) stress and 8) language concerns. 41 . Making WIC widely accessible to families hit hard by COVID-19 is crucial because WIC has been shown to both reduce the prevalence of food insecurity 42, 43 and obesity 44 and is an important contributor to early childhood health.

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In contrast to SNAP and WIC, which provide funds to households so that they might buy food, other programs provide food directly to recipients in specific sites. Both types of programs lessen the burden of food costs on families. The Child and Adult Care Food Program (CACFP), one of the latter types of program, provides cash reimbursement to family day care, child care centers, homeless shelters, and after-school programs for meals and snacks served to children. 45 Attending a CACFP-participating center has been associated with reduction of underweight and overweight with a possible reduction in food insecurity. 46 There have been successful multicomponent intervention trials in child care centers which have prevented excess weight gain especially for children higher weight categories and children with lower socioeconomic status. 47 Both center and home-based child care are subject to state and sometimes local or federal regulatory control, representing an opportunity to influence nutrition and feeding practices in a systematic way. 48

Participation in school meal programs decreases food insecurity of low-income students during the school year. 49, 50 and decreases risk of overweight for girls who have food-insecurity 51 School closures due to the COVID-19 pandemic have exacerbated food insecurity by reducing children's access to school meals. Summer food assistance via electronic benefit cards, reduced the prevalence of very low food security among school aged children by one third and improved children's dietary quality. 52

Food insecurity and obesity are damaging to child health and negatively impact their health as adults. Focusing on policies and programs that take aim at the double burden of food insecurity and obesity is a population health priority. This is especially urgent in light of the effects of COVID-19 on availability and access to healthy food.

Poor diet is now the leading cause of poor health in the US, causing more than half a million deaths per year. 53 The country needs to correct this. The COVID-19 pandemic is laying bare the inequalities in availability of and access to nutritious food. Federal nutrition assistance programs should provide access to the healthiest possible nutrition for children and should ensure that all eligible children and families have healthy nutrition year round.

Overall funding for both SNAP and WIC need to be increased, and specific benefits to families need to rise as well. SNAP benefits to families were derived from the most meager of USDA's four food plans, and even before the pandemic, were inadequate and needed to be increased. 54, 55 The flexibility of SNAP-Ed to assist in food distribution and enrollment in SNAP and the pandemic electronic benefit transfer should be increased through and beyond the pandemic. 56 To maximize the health impact of this program particularly in light of the COVID-19 pandemic, barriers to enrollment and participation should be aggressively addressed by state and federal agencies as well as health care systems.

Studies have shown that adults receiving SNAP benefits improved their diet quality with an increase of fruit and vegetable intake when they received incentives such as; for every dollar of SNAP benefits the household spent on fruits and vegetables in participating retailers, 30 cents in SNAP benefits was added back to their EBT card. 57, 58, 59 Incentives for healthy food are supported by both adult SNAP participants and eligible non participants. 60 SNAP is an ideal vehicle for incentivizing healthy eating both within program requirements and in SNAP education. States should view increasing participation and lowering barriers to participation part of their public health strategy. Healthcare systems should consider SNAP enrollment part of chronic disease treatment.

School meals and snacks may fulfill up to 2/3 of a child's daily nutritional 61 however the nutritional content of these meals can be highly variable. 62 Policies need to assure that all children will receive a healthy high quality school meal and snack in their school setting. Emergency relief during COVID-19 should include requiring FEMA in conjunction with the USDA to coordinate meal distribution through the course of the pandemic, similar to natural disaster relief, extend the expanded electronic benefits transfer through and beyond the pandemic , provide funding relief for school nutrition programs to cover losses incurred during school closures and allow free meals to all children to allow time for processing of new school meal applications in the transition back to school. 56

Compared to non-immigrant families, immigrant families are more likely to experience food insecurity. 63 . One quarter of children under 5, (5,577,000 children in 2018), have at least one parent who is an immigrant with 93.6% of children in these families born in the US. 64 Adults who are documented immigrants who are not part of specific exempt groups i.e. refugees, lawful permanent residents, and have been in the US fewer than 5 years cannot receive SNAP benefits. 65 However, these families have the right to apply for SNAP their U.S. citizen children. 66 . Nevertheless, studies have shown that eligible children of parents who are immigrants are less likely to participate in SNAP when their parents are ineligible. 67 A recent study documented a decrease in SNAP participation among immigrant families and the authors and others suggest that fear among immigrant families related to participation in SNAP due to public charge rulings, lack of education about enrollment of citizen children, need for assurances of data confidentiality of applicant families, and need to reduce anti-immigrant rhetoric are all important strategies to address food insecurity in this population. 68, 69 Conclusion Food insecurity and obesity are damaging to child and adult health. Childhood, a time when optimal nutrition essential for healthy growth and development, is being compromised by systemic factors that we can change. Understanding the impact and overlap of obesity and food insecurity on child health can help us focus on policies that address the overall state of nutrition related illness that compromise the health and well-being of our population.

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