Obesity and Hunger Threaten the Foundations of Child Health

Abstract

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.1Au LE Zhu SM Nhan LA et al.Household food insecurity is associated with higher adiposity among US schoolchildren ages 10–15 years: the healthy communities study.J Nutr. 2019; 149: 1642-1650Crossref PubMed Scopus (15) Google Scholar,2Flórez KR Katic BJ López-Cevallos DF et al.The double burden of food insecurity and obesity among Latino youth: understanding the role of generational status.Pediatr Obes. 2019; 14: e12525Crossref PubMed Scopus (6) Google Scholar Further, and especially important now, both obesity and food insecurity confer increased risk from coronavirus disease 2019 (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.3Trust for America's Health State of Childhood Obesity. The State of Obesity 2018: better policies for a Healthier America. Available at: https://www.tfah.org/report-details/the-state-of-obesity-2018/. Accessed August 31, 2020.Google Scholar, 4Coleman-Jensen A, Rabbitt MP, Gregory CA, et al. Economic Research Report No. (ERR-270) 47. 2019:1–35. Available at: https://www.ers.usda.gov/publications/pub-details/?pubid=94848. Accessed January 12, 2020Google Scholar, 5Rutten LJF Yaroch AL Colon-Ramos U et al.Poverty, food insecurity, and obesity: a conceptual framework for research, practice, and policy.J Hunger Environ Nutr. 2010; 5: 403-415Crossref Scopus (31) Google Scholar 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.4Coleman-Jensen A, Rabbitt MP, Gregory CA, et al. Economic Research Report No. (ERR-270) 47. 2019:1–35. Available at: https://www.ers.usda.gov/publications/pub-details/?pubid=94848. Accessed January 12, 2020Google Scholar 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.6Rogers R Eagle TF Sheetz A et al.The relationship between childhood obesity, low socioeconomic status, and race/ethnicity: lessons from Massachusetts.Child Obes. 2015; 11: 691-695Crossref PubMed Scopus (103) Google Scholar 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.7Rutten LF Yaroch AL Patrick H et al.Obesity prevention and national food security: a food systems approach.ISRN Public Health. 2012; 2012: 10Google Scholar 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 to 13.9%.8Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household Food Security in the United States in 2018, ERR-270, United States Department of Agriculture, Economic Research Service. 2019.Google Scholar 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.9Feeding America. The impact of the coronavirus on food insecurity. 2020. Available at: https://www.feedingamerica.org/research/coronavirus-hunger-research. Accessed August 31, 2020.Google Scholar Childhood obesity and food insecurity co-exist 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.”10Allen LH Causes of nutrition-related public health problems of preschool children: available diet.J Pediatr Gastroenterol Nutr. 2006; 43: S8-12Crossref PubMed Scopus (18) Google Scholar Food insecurity may compromise nutritional quality with the purchase of cheaper, more energy dense foods.11Drewnowski A. The cost of US foods as related to their nutritive value.Am J Clin Nutr. 2010; 92: 1181-1188Crossref PubMed Scopus (266) Google Scholar 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.12Powell LM Chaloupka FJ Food prices and obesity: evidence and policy implications for taxes and subsidies.Milbank Q. 2009; 87: 229-257Crossref PubMed Scopus (327) Google Scholar,13Sturm R Datar A. Body mass index in elementary school children, metropolitan area food prices and food outlet density.Public Health. 2005; 119: 1059-1068Crossref PubMed Scopus (290) Google Scholar 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.14Sturm R Datar A Food prices and weight gain during elementary school: 5-year update.Public Health. 2008; 122: 1140-1143Crossref PubMed Scopus (46) Google Scholar Affordable food pricing for nutritious foods should be considered when policy makers look at economic strategies to drive purchasing.13Sturm R Datar A. Body mass index in elementary school children, metropolitan area food prices and food outlet density.Public Health. 2005; 119: 1059-1068Crossref PubMed Scopus (290) Google Scholar Both obesity and food insecurity negatively affect child and later adult health and well-being. 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,15Thomas MC Miller DP Taryn W Food insecurity and child health.Pediatrics. 2019; 144: 1-9Crossref Scopus (80) Google Scholar and stress.16Casey P Goolsby S Berkowitz C Maternal depression, changing public assistance, food security, and child health status.Pediatrics. 2004; 113: 298-304Crossref PubMed Scopus (232) Google Scholar,17Heflin CM Iceland J Poverty, material hardship, and depression.Soc Sci Q. 2009; 90: 1051-1071Crossref PubMed Scopus (144) Google Scholar Compromise in immune functioning associated with food insecurity may also compromise overall child health status.18Carlsson E Frostell A Ludvigsson J et al.Psychological stress in children may alter the immune response.J Immunol. 2014; 192: 2071-2081Crossref PubMed Scopus (50) Google Scholar 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.19Berkowitz SA, Seligman HK, Basu S. Impact of food insecurity and SNAP participation on healthcare utilization and expenditure. University of Kentucky Center for Poverty Research Discussion Paper Series, DP2017-02.2017; 1-65. Available at: http://www.ukcpr.org/research/discussion-papers. Accessed January 12, 2020.Google Scholar Childhood obesity is a multisystem chronic disease and children with obesity are more likely to have high blood pressure, nonalcoholic fatty liver disease, asthma,20Sharma V Coleman S Nixon J et al.A systematic review and meta-analysis estimating the population prevalence of comorbidities in children and adolescents aged 5 to 18 years.Obes Rev. 2019; 20: 1341-1349Crossref PubMed Scopus (64) Google Scholar type 2 diabetes mellitus, polycystic ovary syndrome, sleep apnea, musculoskeletal disorders, and psychological problems.21Reilly JJ Methven E McDowell ZC Health consequences of obesity.Arch Dis Child. 2003; 88: 748-752Crossref PubMed Scopus (1151) Google Scholar 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.22Sommer A Twig G. The impact of childhood and adolescent obesity on cardiovascular risk in adulthood: a systematic review.Curr Diab Rep. 2018; 18: 91Crossref PubMed Scopus (75) Google Scholar,23Nianogo RA Arah OA Investigating the role of childhood adiposity in the development of adult type 2 diabetes in a 64-year follow-up cohort: an application of the parametric G-formula within an agent-based simulation study.Epidemiology. 2019; 30: S101-S109Crossref PubMed Scopus (2) Google Scholar Childhood obesity results in increased health care costs from prescription drugs, emergency room visits, and outpatient expenditures.24Trasande L Chatterjee S. The impact of obesity on health service utilization and costs in childhood.Obesity. 2012; 17: 1749-1754Crossref Scopus (197) Google Scholar 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 obesity25Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164–S192.Google Scholar and the health effects of hunger.26Council on Community Pediatrics, Committee on Nutrition. Promoting food security for all children.Pediatrics. 2015; 136: e1431-e1438https://doi.org/10.1542/peds.2015-3301Crossref PubMed Scopus (208) Google Scholar 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 to 2016, the prevalence rates for childhood obesity were 13.9% in children 2 to 5 years, 18.4% in children 6 to 11 years, and 20.6% in adolescents 12 to 19 years with an overall prevalence of 18.5%.27Hales CM Carroll MD Fryar CD et al.Prevalence of obesity among adults and youth: United States, 2015–2016.NCHS Data Brief. 2017; 288: 1-8Google Scholar 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.28United States Department of Agriculture Economic Research Service. Food security status of U.S. households in 2018. Available at:https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics.aspx. 2019. Accessed January 12, 2020.Google Scholar Childhood obesity rates have progressed steadily upward from 5% to 6% in the 1970s to 18.5% in 2016.27Hales CM Carroll MD Fryar CD et al.Prevalence of obesity among adults and youth: United States, 2015–2016.NCHS Data Brief. 2017; 288: 1-8Google Scholar 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 (USDA) alone.29USDA Food and Nutrition Service. USDA nutrition assistance programs. Available at: https://www.nal.usda.gov/fnic/usda-nutrition-assistance-programs. Accessed May 28, 2020.Google Scholar 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 (CACFP), School breakfast and lunch program, and the Summer Food Service Program.26Council on Community Pediatrics, Committee on Nutrition. Promoting food security for all children.Pediatrics. 2015; 136: e1431-e1438https://doi.org/10.1542/peds.2015-3301Crossref PubMed Scopus (208) Google Scholar 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 (EBT) 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 5 who are found to be at nutritional risk.29USDA Food and Nutrition Service. USDA nutrition assistance programs. Available at: https://www.nal.usda.gov/fnic/usda-nutrition-assistance-programs. Accessed May 28, 2020.Google Scholar,30USDA Food and Nutrition Service. Supplemental nutrition assistance program. Available at: https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program. Accessed May 28, 2020.Google Scholar In fiscal year 2017, SNAP served an average of 8.6 million households with children each month, representing 42% of all SNAP households.31Cronquist K, Lauffer S. Characteristics of supplemental nutrition assistance program households: fiscal year 2017, US Department of Agriculture, Food and Nutrition Service, Office of Policy Support. 2017;1-129. Available at: http://www.fns.usda.gov/ops/research-and-analysis. Accessed January 12, 2020.Google Scholar 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 prerecession levels and was expected drop even further because of the improving economy.32Rosenbaum D, Keith-Jennings B. Caseload and spending declines have accelerated in recent years. 2019. Available at: https://www.cbpp.org/research/food-assistance/snap-caseload-and-spending-declines-have-accelerated-in-recent-years. Accessed July 24, 2020.Google Scholar 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.33USDA Food and Nutrition Service. SNAP data tables. 2020. Available at: https://www.fns.usda.gov/pd/supplemental-nutrition-assistance-program-snap. Accessed July 23, 2020.Google Scholar SNAP is even more crucial in the economic downturn because increased access to and participation in SNAP reduces the rise in food insecurity for children34Ettinger de Cuba S Chilton M Bovell-Ammon A et al.Loss of SNAP is associated with food insecurity and poor health in working families with young children.Health Aff. 2019; 38: 765-773Crossref PubMed Scopus (39) Google Scholar and risk of obesity in children under 3.35Ettinger de Cuba SA Bovell-Ammon AR Cook JT et al.SNAP, young children's health, and family food security and healthcare access.Am J Prev Med. 2019; 57: 525-532Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Households that experience reduction of SNAP benefits have increased household food insecurity, child food insecurity, housing instability, and energy insecurity.36Leung CW Blumenthal SJ Hoffnagle EE et al.Associations of food stamp participation with dietary quality and obesity in children.Pediatrics. 2013; 131: 463-472Crossref PubMed Scopus (79) Google Scholar 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.37USDA Food and Nutrition Service. FNS response to COVID-19. Available at: https://www.fns.usda.gov/coronavirus. Accessed August 31, 2020.Google Scholar 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,38Black MM Special supplemental nutrition program for women, infants, and children participation and infants’ growth and health: a multisite surveillance study.Pediatrics. 2004; 114: 169-176Crossref PubMed Scopus (99) Google Scholar 3) fears that WIC participation may threaten immigration status39Geltman PL Meyers AF. Immigration legal status and use of public programs and prenatal care.J Immigrant Health. 1999; 1: 91-97Crossref PubMed Google Scholar; 4) fear of stigma from receiving government aid,40Stuber J Schlesinger M Sources of stigma for means-tested government programs.Soc Sci Med (1982). 2006; 63: 933-945Crossref PubMed Scopus (124) Google Scholar 5) difficulty with transportation, 6) need to miss work, 7) stress, and 8) language concerns.41Liu CH Liu H. Concerns and structural barriers associated with WIC participation among WIC-eligible women.Public Health Nurs. 2016; 33: 395-402Crossref PubMed Scopus (24) Google Scholar 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 insecurity42Metallinos-Katsaras E. Gorman K.S. Wilde P. et al.A longitudinal study of WIC participation on household food insecurity.Matern Child Health J. 2011; 15: 627-633Crossref PubMed Scopus (63) Google Scholar,43Kreider B Pepper JV Roy M Identifying the effects of WIC on food insecurity among infants and children.South Econ J. 2016; 82: 1106-1122Crossref Scopus (43) Google Scholar and obesity44Pan L Blanck HM Park S et al.State-specific prevalence of obesity among children aged 2–4 years enrolled in the special supplemental nutrition program for women, infants, and children—United States, 2010–2016.MMWR. 2019; 68: 1057-1061Crossref PubMed Scopus (15) Google Scholar and is an important contributor to early childhood health. 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 programs, provides cash reimbursement to family day care, child care centers, homeless shelters, and after-school programs for meals and snacks served to children.45Heflin C, Arbeaga I, Gable S. The child and adult care food program and food insecurity. University of Kentucky Center for Poverty Research Discussion Paper Series, DP 2012-10. Available at:http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.834.7476&rep=rep1&type=pdf. Accessed January 12, 2020.Google Scholar Attending a CACFP-participating center has been associated with reduction of underweight and overweight with a possible reduction in food insecurity.46Korenman S Abner KS Kaestner R et al.The child and adult care food program and the nutrition of preschoolers.Early Child Res Q. 2013; 28: 325-336Crossref PubMed Scopus (62) Google Scholar 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.47Sisson SB Krampe M Anundson K et al.Obesity prevention and obesogenic behavior interventions in child care: a systematic review.Prev Med. 2016; 87: 57-69Crossref PubMed Scopus (120) Google Scholar 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.48Hassink SG Early child care and education: a key component of obesity prevention in infancy.Pediatrics. 2017; 140e20172846Crossref PubMed Scopus (12) Google Scholar Participation in school meal programs decreases food insecurity of low-income students during the school year49Huang J Barnidge E Kim Y Children receiving free or reduced-price school lunch have higher food insufficiency rates in summer.J Nutr. 2015; 145: 2161-2168Crossref PubMed Scopus (36) Google Scholar,50Bartfeld JS Ahn HM. The school breakfast program strengthens household food security among low-income households with elementary school children.J Nutr. 2011; 141: 470-475Crossref PubMed Scopus (79) Google Scholar and decreases risk of overweight for girls who have food-insecurity.51Jones SJ Jahns L Laraia BA et al.Lower risk of overweight in school-aged food insecure girls who participate in food assistance: results from the panel study of income dynamics child 46development supplement.Arch Pediatr Adolesc Med. 2003; 157: 780-784Crossref PubMed Scopus (99) Google Scholar 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.52Collins AM Klerman JA Briefel R et al.A summer nutrition benefit pilot program and low-income children's food security.Pediatrics. 2018; 141e20171657Crossref PubMed Scopus (16) Google Scholar 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 United States, causing more than half a million deaths per year.53US Burden of Disease CollaboratorsThe state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US states.JAMA. 2018; 319: L1444-L1472Crossref PubMed Scopus (703) Google Scholar 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.