INSTITUTE OF MEDICINE

AS A PROFESSION:

Physician Advocacy ConferenceNovember 18-19, 2010

Dr. Deborah A. FrankProfessor of Pediatrics, Boston University School of MedicineFounder and Principal Investigator, Children’s HealthWatch

Founder and Director, Grow Clinic for Children, Boston Medical Center

WE SIT BESIDE THE GIANTS ON WHOSE SHOULDERS WE STAND

How Did I Get Here?

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You were Either Hospital or Orphanage

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How Did I Get Here?

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Riding Two Advocacy Horses

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Trouble with Women is They Take Everything Personally!

Children’s HealthWatch

Collect data in five urban, safety-net hospitals

Produce scientific research

that is original and timely

Share evidencewith state and national partners to inform policy choices

Children’s HealthWatch• Deborah A. Frank, MD (Boston)• Maureen Black, PhD (Baltimore)• John Cook, PhD (Boston)• Mariana Chilton, PhD (Philadelphia)• Carol Berkowitz, MD (Los Angeles)• Patrick Casey, MD, MPH (Little Rock)• Diana Cutts, MD (Minneapolis)• Alan Meyers, MD, MPH (Boston)• Stephanie Ettinger de Cuba, MPH (Boston)• Timothy Heeren, PhD (Boston)• Sharon Coleman MPH (Boston)• Megan Sandel MD (Boston)• Zhaoyan Yang, MS (Boston)

Why Watch Children Birth to 3?

Official Poverty Rates by Age Group

22%

18%

14%

0%

5%

10%

15%

20%

25%

Chi ldr en Under Age 6 Chi ldr en Age 6 or Older Adults 18-64

Data Supports Sensitive Period Hypothesis

Sensitive Period Hypothesis: Insult during brain growth spurt most likely to be irreversible

Poverty in early childhood has more severe and lasting effects on later health, cognition, and

behavior than poverty at later ages (Duncan,Ziol-Guest,Kalil, Child

Development,2010)

Food Insecurity

Limited or uncertain availability of nutritionally adequate and

safe foods or limited or uncertain ability to acquire acceptable

foods in socially acceptable ways

Source: USDA

Help Connect the Dots

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FOOD INSECURITY, HUNGER, AND MALNUTRITION ARE ALL

– Child Health Issues– Adult Health Issues– Mental Health Issues– Educational Issues– Political Issues– Moral Issues

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CHANGES IN FAMILY SURVIVAL RESOURCES RAPIDLY REFLECTED IN

HEALTH, LEARNING, AND GROWTH OF YOUNG CHILDREN

The Problem to Address: Food Insecurity: Highest Since 1995

Overall, households with children (<18) had nearly twice the rate of food insecurity (21.3 percent) as those without children (11.3 percent).

Families with the youngest children are Families with the youngest children are most at risk for food insecurity.most at risk for food insecurity.25.4 percent of households with children 25.4 percent of households with children under six are food insecure in the U.Sunder six are food insecure in the U.S. That translates to 9, 647. 000 American kindergarteners, preschoolers, toddlers, and infants. (USDA data,2009)

Puzzle of Poverty and Obesity

• Cyclical food deprivation/overeating• Need to minimize per calorie cost• Lack of access to fruits and vegetables in low

income neighborhoods• Lack of opportunity for safe exercise in low

income neighborhoods• ? Stress hormones

Real Cost of a Healthy Diet

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Can parents afford to purchase healthy food?

$1.33 $2.79880 calories880 calories

Tight budgets limit food choices; cheap calories provide little nutritional value.

Drewnowski 2004

Stop and Shop Price Check Sept 2010

The cheap foods that make adults fat starve children of absolutely

essential nutrients. Children who do not receive protein and other

nutrients during early development are damaged for the rest of their

lives.Dr. Margaret Chan WHO

brain

GROWN UP BRAINS NEED NUTRIENTS TOO

Help Connect the Dots

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Energy Insecurity and the Heat or Eat Dilemma

Limited or uncertain access to home heating or electricity

Moderately energy insecure: received a letter threatening utility shut-off in the last year

Severely energy insecure: actual utility shut-off, at least one day with no energy for heating or cooling, or have used a cooking stove as a heating source in the last year

Effects of Energy Insecurity

Compared with infants and toddlers in households that were energy secure, those in households with just moderate energy insecurity were:

• More than twice as likely to live in a food-insecure household

• 79% more likely to be child food insecure • 34% more likely to be reported in fair or poor health • 22% more likely to have been hospitalized since birth

Housing Insecurity

Household is overcrowded, doubled up with another family and/or has moved twice or

more in the last year

Effects of Housing Insecurity

Compared to children in families that are stably housed, children in families who are housing insecure are more likely to be:

• Food Insecure• In poor health• At risk for developmental delays

Economic Hardship

Food Insecurity

Housing Insecurity

Energy Insecurity

Scoring: Cumulative Hardship Index

• Score of 0, 1, or 2 for each hardship0= Secure1= Moderately insecure2= Severely insecure

• Total possible score of 60= No Hardship1-3= Moderate Hardship4-6= Severe Hardship

Majority of Families Experience Hardship (N=7,141)

• 37% (N=2,640) No hardship• 57% (N=4,075) Moderate hardship • 6% (N=426) Severe hardship

• Increasing scores on the cumulative hardship index, indicating worsening material conditions

What Do We Mean by Child Wellness?

• Good or excellent health

• No hospitalizations• Not at

developmental risk• Not overweight or

underweight

Results: Bivariate (N=7,141) Hardship and Wellness

OutcomeOutcome

No No HardshipHardship

(N=2640)(N=2640)

Moderate Moderate Hardship Hardship (N=4075)(N=4075)

Severe Severe Hardship Hardship (N=426)(N=426)

WellnessWellness(p<0.0001)(p<0.0001)

46% 46% (N=1209)(N=1209)

42% 42% (N=1712(N=1712))

35% 35% (N=148)(N=148)

Multivariate Logistic Regression I

Children with severe vs. no hardship

had AOR

0.66 (95% CI 0.52, 0.84, p=.001)

of “wellness” after controlling for covariates

Multivariate Logistic Regression II

Children with severe vs. moderate hardship had AOR

0.74 (95% CI =0.59, 0.93, p=.01)

of “wellness” after controlling for covariates

Multivariate Logistic Regression III

Children with moderate vs. no hardship had AOR

0. 89 (95% CI =0. 80,0.99, p=.01)

of “wellness” after controlling for covariates

Can We Fix It?

Emergency Fixes

EMERGENCY FOOD NETWORK

Is That All That Can Be Done?

Fixing Hunger and Hardship Long-Term is a Political Issue

Which Programs Promote Healthy Height and Weight?

• WIC• CHILDCARE FEEDING• LIHEAP• HOUSING SUBSIDY

Which Programs Decrease Poor Health/Hospitalizations?

• WIC• SNAP• LIHEAP• CHILDCARE FEEDING

Which Programs Decrease Developmental Risk?

• SNAP• WIC• HOUSING SUBSIDIES

Riding Two Advocacy Horses

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PERINATAL EFFECTS I

• Fetal Hypoxia

• Increased risk spontaneous abortion and still birth

PERINATAL EFFECTS II

• Low Apgars• Depressed

– Birth Weight– Head Circumference– Length

• ? Congenital Abnormalities

POSTNATAL EFFECTS

• Increased risk SIDS• Attention Deficits• Lower IQ• Increased risk exposed child will grow up to be adult

addict• Sleep problems

Stone et. al. Behav Sleep Med 7:196-207, 2009Buka et. al. Am J Psychiatry 160:1978-84, 2003

South Carolina Judges Speak

• “Now this little baby is born with crack, when he is seven year old, they have an attention span that long. They can’t run. They just run around in class like a little rat. Not just black ones. White ones too.” (State v. Collins Pickens County 1991)

• “Sick and tired of these girls having these bastard babies on crack cocaine.” (State v. Crawley 1994)

atlanta meeting

Buying Into Stigma Jeopardizes Mothers and

Children

FERGUSON V CITY OF CHARLESTON

• Health professionals selectively screened urine of medically indigent obstetric for cocaine

• Reported positive results to police• Pregnant and post-partum women (all but one

African American) arrested for possession of an illegal drug, delivery of drugs to a minor, or child abuse

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FERGUSON VS CITY OF CHARLESTON

SUPREME COURT RULED POLICY UNCONSTITUTIONAL 6-3 IN MARCH 2001

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BUT NOW THERE ARE 40 NEW PROSECUTIONS IN ALABAMA

ALONE

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Prevalence of Food Insecurity in the United States, 1999–2008.

Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

Children’s Share of Domestic Federal Spending

From 1960 to 2008 children’s share of federal domestic spending declined from 20% to 15%

WHY BOTHER?

When You Can’t Do Anything Else: Document!

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Thank You!www.childrenshealthwatch.org

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