Below are a few of the many findings from Children’s HealthWatch data which have been published in peer-reviewed journals, policy reports, and/or presented at national scientific meetings. Many of these findings have also been highlighted in Congressional testimony and media coverage.
Food insecurity is limited or uncertain access to enough nutritious food for all household members to lead an active and healthy life.
Child Food Insecurity Intensifies the Harmful Effects of Household Food InsecurityThere are various levels of food security – food secure (which includes households that have both high food security and marginal food security), low food security, and very low food security (previously known as food secure, food insecure, and food insecure with hunger). In addition, a Child Food Security Scale has been validated by USDA. The Child Food Security Scale measures household food security with an 18-question survey that can identify a more severe level of deprivation than is detected by the household-level measure alone. Child food insecurity occurs when caregivers are no longer able to buffer children from scarce household food resources.
As of December 2012, in Children’s HealthWatch’s five-city sample of low-income families with children, 21.7% were food insecure.Compared to young children in food secure households, infants and toddlers in food insecure households are:
- 30% more likely to have a history of hospitalization.
- 90% more likely to be reported in fair or poor health.
- Nearly twice as likely to have iron deficiency anemia.
- Two-thirds more likely to be at risk for developmental delays.
Household and Child Food Insecurity Are Not the Whole PictureEven at very low levels of food insecurity, children suffer significant negative health and developmental effects. Children under age three in marginally food-secure households were found to have health outcomes that are significantly worse than children in fully food-secure households. They are more likely to:
- Be in fair/poor health.
- Be at risk for developmental delays.
- Have been hospitalized since birth.
- Lack stable housing.
- Live in households with inadequate heating and cooling.
- Have caregivers experiencing symptoms of depression.
- Have caregivers in fair/poor health.
SNAP protects children in the critical early years of life. As of December 2012, 45.6% of families in the Children's HealthWatch five-city sample received SNAP. Children's HealthWatch has found that, in comparison to children whose families were eligible but did not receive SNAP, young children whose families received SNAP benefits were significantly less likely to be at risk of:
- Underweight (an indication of undernutrition)
- Developmental delays
ARRA Increase in SNAP Benefits Protected Children’s HealthIn 2009, SNAP recipients received increased assistance when ARRA raised SNAP benefits for all participants. This increased benefit is scheduled to be eliminated in November 2013. Yet Children's HealthWatch research underscore that this change will be harmful to young children. Children’s HealthWatch research demonstrated that young children in families receiving SNAP in the two years after the ARRA were significantly more likely to be classified as “well” than young children whose families were eligible but did not receive SNAP. What is a Well Child? A child who is not overweight or underweight, and whose parents report that s/he is in good health, has never been hospitalized, and is developing normally for his/her age. The ARRA increase helped bridge the gap between food costs and limited family resources and thus improved child health. The USDA Economic Research Service has also shown that the increased SNAP benefit was essential in slowing the rate of food insecurity at the national level during the Great Recession. These results underscore the need to protect and improve, rather than decrease, SNAP benefit levels; higher SNAP benefit levels have a positive impact on young children’s health. To read our policy brief, Boost to SNAP Benefits Protected Young Children’s Health, click here.
The Real Cost of a Healthy Diet Project, a collaboration of Children's HealthWatch at Boston Medical Center and Center for Hunger-Free Communities at Drexel University's School of Public Health, investigated whether low-income households can buy food for a healthy diet using the maximum SNAP benefit in their neighborhood food stores. In 2005, the project conducted a pilot, which resulted in the report, The Real Co$t of a Healthy Diet: Healthful Foods Are Out of Reach for Low-Income Families in Boston, Massachusetts. Building upon this pilot work, Children's HealthWatch and the Drexel School of Public Health published findings about the availability and affordability of healthy food in Boston and Philadelphia in the September 2008 report, Coming Up Short: High food costs outstrip food stamp benefits. In November 2011, the results of the latest study were released in the report, The Real Cost of a Healthy Diet: 2011. The study examined whether a healthy diet was available and affordable on a SNAP budget at neighborhood food stores in Philadelphia. Results: The overall average monthly cost of the items on the TFP shopping list in all stores surveyed was $864, which is approximately 29% higher than the maximum SNAP benefit. This represents a $196 monthly shortfall for families who receive the maximum SNAP benefit. This monthly shortfall would have been larger had SNAP benefits not been raised across-the-board in 2009 under the American Recovery and Reinvestment Act (ARRA). Small stores remain the most convenient and prevalent type of store in many low-income neighborhoods though they are also the most expensive. Because so many families who receive SNAP rely on small stores as a primary place to purchase food, they are likely to experience the greatest shortfalls when trying to buy a healthy diet.
Searching for fruit and other healthy options: The TFP shopping list used in this study is comprised of 104 items. On average, 35 percent of the items were unavailable in participating stores. Half of the TFP items were missing at small stores, many of which were fresh fruits and vegetables and other healthy, nutrient-rich foods. Our research shows that not only are healthy foods out of reach financially for many SNAP recipients, they are often unavailble at small stores in many low-income neighborhoods.
Conclusion: The Thrifty Food Plan is not keeping up with changes in our understanding of a healthy diet, challenges in urban neighborhoods, and steadily increasing food prices.
Solutions within Reach: Policy Recommendations:
- Invest in SNAP over the short and long term to boost the economy and reflect changing food price realties. USDA studies show that every $5 of food stamp benefits generates almost twice as much ($9.20) in local economic activity.
- Protect SNAP's existing entitlement structure, allowing the program to expand with rising need and to shrink as the economy improves and families' earnings increase. This structure has been crucial in protecting low-income households from hunger during natural disasters and economic recessions.
- Maintain ARRA benefit level improvements past their current expiration date of November 2013. Children's HealthWatch and other research have found the ARRA benefit boost good for children and families, protecting their health and food security. Click here to read our brief on the ARRA benefit boost.
- Replace the USDA's Thrifty Food Plan with the Low-Cost Food Plan as the basis for the maximum SNAP benefit. The Low-Cost Food Plan is a more accurate reflection of food pricing in struggling urban and rural communities.
WIC has a Powerful Effect on the Health of Young ChildrenResearch on WIC has demonstrated repeatedly that WIC is a very effective program for protecting the health of infants and young children. Children’s HealthWatch has found that compared to children who are likely eligible but not receiving WIC due to access problems, children who receive WIC are more likely to:
- Be in excellent or good health
- Be food secure
- Have a healthy weight for their age
WIC Decreases the Risk of Developmental Delays in Young Children.Children are considered at risk for developmental delays when there are significant concerns about their ability to speak and understand language, their fine and gross motor skills, social/emotional behavior, and/or ability to learn in school. Children’s HealthWatch findings about reduced risk for developmental delays are consistent with a long history of research showing WIC to be effective in protecting young children’s birth outcomes, health and development.
WIC is a Sound and Effective Investment in our Nation’s FutureWIC is cost‐effective: every $1.00 spent on WIC results in savings of between $1.77 and $3.13 in health care costs. The cost savings are due in part to WIC’s effectiveness in reducing rates of low birth weight and improving rates of childhood immunization. Given the tight schedule of young children’s brain development, timely availability of adequate nutrition is essential. To read our report, “Feeding our Future: Growing up Healthy with WIC,” click here. To read our policy action brief, “WIC Improves Child Health and School Readiness," click here. To read out peer-reviewed article, "WIC Participation and Attenuation of Stress-Related Child Health Risks of Household Food Insecurity and Caregiver Depressive Symptoms," click here.
The federal Child and Adult Care Food Program (CACFP) reimburses eligible child care providers for meals and snacks that meet specific nutritional guidelines. In addition, the program supports providers through on-site visits, group classes, and ongoing technical assistance.
Because CACFP is administered at the child care provider level and parents cannot apply individually, many do not know whether their child participates. This has complicated collecting data that could connect child health to program participation. Children’s HealthWatch identified a subset of children in its database who are highly likely to be participating in CACFP. Of these children in child care centers between 13 months and three years of age, whose parents receive a child care subsidy, Children’s HealthWatch compared children whose meals were supplied from home and children whose meals were supplied by the child care provider. We found that children whose meals were supplied by the child care provider were:
- 28% less likely to be in fair or poor health.
- 26% less likely to be hospitalized.
- More likely to have a healthy weight and height for their age.
The importance of extending CACFP’s reach to more children in need is clear. Participation by child care centers is increasing yet fewer than half of centers in the U.S. are enrolled. Family child care provider participation in CACFP has dropped 27 percent since the introduction of a complex and time-consuming two-tiered reimbursement system in 1976 that has deterred participation. Yet, for many families, family child care remains the most affordable source of care
To read our policy action brief, “Child Care Feeding Programs Support Young Children’s Health Development,” click here.
To read our publications on food insecurity and CACFP, click here.
Through 2012, in Children’s HealthWatch’s five-city sample of low-income families with children, 26% were energy insecure. Energy insecurity occurs when there is limited or uncertain access to enough home energy to sustain a healthy and safe life. Energy-insecure families have, for example, had their utilities shut-off, have gone without heat for a day or more or have used their cooking stove for heat. Compared with infants and toddlers in households that were energy secure, those in households with moderate energy insecurity were:
- More than twice as likely to live in a food-insecure household
- 79% more likely to be child food insecure (a more severe form of food insecurity)
- 34% more likely to be in fair or poor health
- 22% more likely to have been hospitalized since birth
- More than three times as likely to live in a food-insecure household
- More than three times as likely to be child food insecure (a more severe form of food insecurity)
- 36% more likely to be in fair or poor health
- 82% more likely to be at risk for developmental delays
LIHEAP, the Low Income Home Energy Assistance Program, is the federal government’s only program aimed at assisting families with utility expenses. LIHEAP operates on a first-come, first-served basis, so funds often run out part way through the heating season, and, depending on yearly funding, may not serve all those who are eligible. We see this in our data, too. Among low-income Children’s HealthWatch families eligible for LIHEAP, only 17.4% of families received energy assistance. Despite its limited reach, LIHEAP has powerful effects on children’s health and growth. Compared to infants and toddlers in families who receive LIHEAP, infants and toddlers who do not receive the benefit are:
- Significantly more likely to be underweight.
- 23% more likely to be at nutritional risk for growth problems.
- 32% more likely to be admitted to the hospital on the day of the Children’s HealthWatch interview.
A safe, stable home is important for children’s physical and mental health today and their growth and learning abilities tomorrow. However, housing is often a family’s largest single expense. Children’s HealthWatch research illustrates the connections between unstable housing,strained budgets, and poor health outcomes for families with children. As of December 2012, 40.5% of Children's HealthWatch were housing insecure. Housing insecurity occurs when families are living in overcrowded conditions (e.g. more than 2 people per bedroom or doubled up with other families) and/or have moved two or more times in the past year. Compared to children in housing secure families, children in housing-insecure families are more likely to be:
- Food insecure
- Child food insecure (a more severe form of food insecurity)
- In fair or poor health
- At risk for developmental delays
Children’s HealthWatch had previously demonstrated that housing insecurity takes a serious toll on children’s health and family stability. This research project expanded on that work with the goal of providing policy makers with research within a local/state context for informing policy. Children's HealthWatch analyzed the data from each of our research sites (Boston, Baltimore, Little Rock, Minneapolis and Philadelphia) separately to better understand the effects of housing insecurity on families. Our evidence showed that stable, affordable housing improves the health of our children and the well-being of families.
- Children's HealthWatch researchers analyzed survey data collected from caregivers of children under four between 2005 and 2011.
- Data was analyzed separately by research site.
- To ensure the research sample was composed of low-income families, those with private insurance were excluded.
- The referent group for the analysis was stably housed families.
- Stably housed was defined as:
- Families who haven't moved two or more times in the last twelve months,
- Families who were not living in spaces where there are more than two people per bedroom or where families are doubled up temporarily with another family for financial reasons
- Families who were not behind on rent at any point in the last twelve months.
- Stably housed was defined as:
A Sample of our FindingsBaltimore, MD: Children's HealthWatch found that 50% of the 5,000 surveyed Baltimore caregivers in our sample were housing insecure. Young children in families from Baltimore who were crowded or behind on rent were approximately 22% less likely to be classified as “well” on a composite scale of child well-being than were children in stably housed families. Boston, MA: Children's HealthWatch found that 49% of the approximately 6000 families that we surveyed were housing insecure. Young children in families who are behind on rent in Boston are 52% more likely to experience developmental delays.
Little Rock, AR: In the sample of 5,000 Arkansas families with children, Children's HealthWatch found that about 51% of families were housing insecure. Compared to children in stably housed families, children in households who moved frequently were 34% more likely to be underweight (a sign of undernutrition).Philadelphia, PA: Children's HealthWatch analyzed data from 4,500 Philadelphia families and found that over 50 percent were housing insecure. Compared to children in stably housed families, those whose families were behind on rent or moving frequently were significantly more likely to be in fair or poor health or at risk for developmental delays Minneapolis, MN: Children's HealthWatch analyzed data from 6,000 young Minneapolis children and their caregivers collected between 2005 and 2011 at the Hennepin County Medical Center. We found that approximately 67% of families were housing insecure. Compared to children in securely housed families, we found children in housing insecure families were 1.27 to 2.23 times more likely to be in fair or poor health.
ConclusionThe following findings held up across our samples in Baltimore, Boston, Little Rock, Minneapolis and Philadelphia:
Young children in housing insecure families are more likely to be household and child food insecure.
Young children in families who moved frequently or were behind on rent are at increased risk of poor health and developmental delays.
Families who are behind on rent are much more likely to be unable to afford basic neccesities such as food, energy and healthcare.
Solutions within Reach: Policy Recommendations
Our research suggests the following policy actions will have a positive effect on children's health and family stability:
- Increased investments in affordable housing, such as housing trust funds.
- Short term and long term interventions to help stabilize families housing.
- Greater coordination between affordable housing programs and safety-net programs that help families cope with homelessness.
Housing affordability is a public health and an economic development issue. Low-income families face an almost impossible challenge in finding affordable housing. Many are paying much more than the federal standard of 30% of income for housing, leaving them few resources to cover all of their other basic needs. In addition, there are long waiting lists for housing subsidies, as the supply is not available to meet the demand.
- Among low-income Children’s HealthWatch families eligible for housing subsidies, housing assistance was received by only 25% of the families.
- 19% more likely to be food secure
- 28% less likely to be seriously underweight
- 35% more likely to be classified as “well” on a composite indicator of child health
Children’s HealthWatch research shows the very young children in families that experience multiple hardships—in this case, not enough nutritious food, inadequate or inconsistent and access to utility service, and unstable housing, suffer negative health effects, many of which have life-long consequences. Cumulative hardship is assessed using a numerical scale to measure severity of food, energy and housing insecurity. The scores are summed across the three components to arrive at a total hardship score. As of December 2012, 60.8% of Children's HealthWatch's sample experienced cumulative hardship (54.7% moderate hardship, 6.1% severe). Children’s HealthWatch found that compared to those with no hardship, children with moderate hardship were:
- 11% less likely to be classified as well
- 21% more likely to be at risk for developmental delay
- 35% less likely to be classified as well
- 120% more likely to be at risk of developmental delay
- 30% of all families suffer from energy insecurity
- Moderately housing insecure families are more likely to be food insecure
- Moderately housing insecure families are more likely to be energy insecure
Children's HealthWatch has created and validated a composite indicator of child wellness that synthesizes measures of growth, health, and developmental risk. A “well child” is defined as:
- in good to excellent heath (by caregiver report, vs. fair or poor health)
- No hospitalizations since birth
- Not identified as developmentally “at risk” on the PEDS
- Weight-for-age > 5th percentile < 95th percentile
- Weight-for-height > 10th percentile < 95th percentile
- BMI < 85th percentile for children > 24 months of age
As of December 2012, about 25% of Children's HealthWatch sample received TANF. Compared to TANF families whose benefit was not decreased, infants and toddlers with terminated or reduced TANF assistance are:
- 30% more likely to have a history of hospitalization.
- 50% more likely to be in food insecure households.
- 90% more likely to be admitted to a hospital at an ED visit.
Young children of color and children of immigrants are disproportionately more likely to be poor and food insecure than their White peers, putting these children at higher risk for health and development problems. More than 80% of the Children’s HealthWatch dataset is made up of children of color, hence we are uniquely positioned to understand the effects of public policy on the health, growth, and development of these young children Compared to Black children who live in low-income but food-secure households, Black children living in low-income, food-insecure households experience 57% higher odds of their parents identifying significant developmental concerns. TANF Compared with Black infants and toddlers whose TANF family benefit was not reduced in the past year:
- Black infants and toddlers whose TANF family benefit was reduced were 56 percent more likely to be food insecure.
- Black infants and toddlers whose TANF family benefit was sanctioned were 78 percent more likely to be food insecure.
- Black infants and toddlers whose SNAP/food stamp family benefit was reduced were 33 percent more likely to be food insecure.
- Black infants and toddlers whose SNAP/food stamp family benefit was sanctioned were 84 percent more likely to be food insecure.
- Black infants and toddlers whose SNAP/food stamp family benefit was reduced were 38 percent more likely to be reported as being in fair or poor health.
- 56% more likely to be at nutritional risk for growth problems.
- More than twice as likely to be underweight (as measured by being less than or equal to two standard deviations below the mean for weight-for-age).
- More likely to be shorter in height (as measured by height-for-age z-score).
- 33% more likely to be underweight (as measured by being less than or equal to two standard deviations below the mean for weight-for-age).
- More likely to be shorter in height (as measured by height for- age z-score).
- 29% more likely to be at nutritional risk for growth problems (less than the fifth percentile for weight-for-age, or less than the tenth percentile for weight-for-height).
- More likely to have a lower weight (as measured by weight for- age z-score).
Latino ChildrenCompared to Latino children who live in low-income but food-secure households, Latino children living in low-income, food-insecure households experience more than twice the odds of their parents identifying significant developmental concerns. TANF Compared with Latino infants and toddlers whose TANF family benefit was not reduced in the past year:
- Latino infants and toddlers whose TANF family benefit was reduced were more than twice as likely to be food insecure.
- Latino infants and toddlers whose TANF family benefit was sanctioned were 63% more likely to be food insecure.
- Latino infants and toddlers whose SNAP/food stamp family benefit was sanctioned were more than twice as likely to be food insecure.
- More likely to have a lower weight and be shorter in height (as measured, respectively, by weight-for-age and height-for-age z-scores).
99% more likely to be short in height (less than or equal to two standard deviations below the mean for height-for-age).
Compared to children of US-born mothers, children of immigrant mothers are:
- 26% more likely to be at risk for fair or poor health.
- More than twice as likely to be at risk for food insecurity among newly arrived immigrants.
35% less likely to be in fair or poor health
28% less likely to have a history of hospitalizations.
Significantly higher in weight-for-age and length-for-age z scores than those who are not breastfed.
Compared to mothers who do not report symptoms of depression, mothers who do report depression are:
60% more likely to describe their child's health as fair or poor.
More than twice as likely to experience household food insecurity.
50% more likely to report decreased welfare support and/or lost SNAP.
Compared to caregivers in food secure households, caregivers in food insecure households are:
Two-thirds more likely to report their children as being at developmental risk.
The Parents’ Evaluation of Developmental Status (PEDS) is both an evidence-based surveillance tool and a screening test, and is used to assist in the detection of developmental disabilities for children from birth to 8 years of age. PEDS consists of 10 questions that assess cognition, expressive and receptive language, fine and gross motor behavior, socioemotional development, self-help, and learning. PEDS has high sensitivity and identifies 74% to 80% of children with developmental disabilities—in keeping with standards for developmental screening tests and commensurate with the accuracy of measures that take much longer to administer. Click here to go to the website for the PEDS test. PEDS was added to the Children's HealthWatch survey in 2004 and is administered to all caregivers with children who are at least 4 months old, the age at which the screen becomes more readily interpretable. Children's HealthWatch has found that children in food insecure families are significantly more likely than those in food secure households to screen positive on the PEDS [AOR 1.77, 95% CI 1.23-2.56]. To read Children's HealthWatch's article "Household food insecurity: associations with at-risk infant and toddler development" published in Pediatrics, click here.