INTRODUCTIONS: 3. INFLUENCE OF FOOD COSTS AND

FOOD CULTURE

___________________________________________________________________

Alan Meyers

Associate Professor of pediatrics

Boston University School of Medicine

Robert J Karp, MD

Department of Pediatrics

SUNY-Downstate Medical Center

Brooklyn, NY

___________________________________________________________________

Pre-Test Questions

Q1. Which of the following is the most likely to be associated with obesity in childhood?

a. Living in a family with an income below the poverty level.

b. Living in a family with an income between poverty level and three times poverty.

c. Living in a family with an income greater than three times the poverty level.

d. All of these children are equally `at-risk’ for obesity

Q2. The last dollar spent by a poverty level family is likely to go:

a. A trip to the movies

b. An advertised brand of sneakers

c. Food

d. A present for the children

Q3. Pick the phrase that best described differences in growth in populations.

a. Approximately 3/4 of the variance for growth is governed by environmental influences with the heredity increasing risk for short stature.

b. Approximately 3/4 of the variance for growth is governed by genetic influences with the environment increasing risk for short stature.

Q4. Supplemental food programs work by providing extra income to poverty level families for:

a. A trip to the movies

b. An advertised brand of sneakers

c. Food

d. A present for the children

Objectives

On completion of this module, residents will be able to:

Recognize the impact of poverty and "food insecurity" on children and families.
Identify elements of food culture.
Adapt recommendations to families using their apprectiaion for elements of food culture, cost and insecurity.
Facilitate the opportunity of their patients to obtain nutrition support.

Facilitator's Preperation

This module is derived from

Karp RJ, Cheng C, Meyers AF. (2005)The appearance of discretionary income: Influence on the prevalence of under- and overnutrition. International Journal of Health Inequitieshttp://www.equityhealthj.com/content/4/1/10

See also:

Bhattacharya J, DeLeire T, Haider S, Currie J. Heat or Eat? Cold-weather shocks and nutrition in poor American families. American Journal of Public Health. 2003; 93: 1149-54.

Frank DA, Roos N, Meyers AM, et al. Seasonal variation in weight for age in a pediatric emergency room. Pub Health Rep 1996; 111: 366 71.

Immink MDC. Purchasing power and food consumption behavior: how poverty level is defined. In: Sanjur D, ed. Social and cultural perspectives in nutrition. Engelwood cliffs NJ: Prentice Hall, 1982; 91-122.

Karp RJ. The problem of changing food habits -1: how habits are formed. In: Karp RJ, ed. Malnourished Children in the United States: Caught in the Cycle of Poverty. New York: Springer Publishing Co., 1993; 194-211. (fig 18.1)

Karp RJ. (1999 and 2005 Malnutrition among children in the United States. The impact of poverty. (in) Shils,ME, JA Olson, M Shike, and AC Ross. (eds) Modern nutrition in Health and Disease, 9th and 10th editions. Williams and Wilkins, Baltimore, MD.

Karp, RJ (2002) The dimensions of poverty among children in the United States: an exposition of causes and consequences. Epilogue to the Curriculum for Poor and Underserved Children of the Ambulatory Pediatric Association, 2002 http://www.servingtheunderserved.org.html.

Meyers A, Frank D, Roos N, et al. Housing subsidies and pediatric undernutrition. Arch Ped Adolesc Med 1995;149:1079 84.

Background

Undernutrition affects the poorest children and is characteristic of societies where diminished resources are available to those without entitlement to adequate nutrition — usually the poor. By contrast, overnutrition and nutrient imbalance are likely to occur among those with higher, but not yet adequate, incomes or resources or entitlement for nutritious food — especially in those families living at the cusp of poverty and self-sufficiency.

The prevalence of these forms of malnutrition is highly influenced by the rate of appearance of discretionary income. Discretionary (alternatively "disposable") income refers to funds available after obtaining necessities (food, housing, health care and the expenses of maintaining employment — day care, clothes and transportation). For families living in poverty, the last dollar earned is spent on necessities. Undernutrition is common. By contrast, likelihood for obesity or imbalance increases when that last dollar is earned without certainty that it is available for discretionary spending.

Low-income children in the U.S. have poorer nutritional status than their middle-and upper-income peers. There continues to be a substantial “social gradient” in nutritional status in the U.S. child population for both macronutrient and micronutrient nutrition (Hyperlink to Iron deficiency and see below). Poverty level children in the United States may be both under-nourished (iron deficient) and over-nourished (obese) at the same time

The best measure of macronutrient (energy) nutritional status in children is their growth parameters. [Hyperlink to nutritional assessment] This is internationally recognized as one of the most reliable measures of health and well-being of a community. Classic studies by Gruelich in the 1950s demonstrated that the Japanese-American population approached the U.S. standard in child growth over several generations of residence in California, while the population of postwar Japan remained far below the U.S. norm, despite sharing a common genetic heritage. Studies in poor countries have consistently shown that the growth parameters of the children of the elite classes are very close to those of the children who comprise the U.S. reference population; it has been estimated from these studies that approximately three-fourths of the variation in growth between large national populations is a consequence of undernutrition associated infectious illnesses and gastroenteritis. Only one-fourth is due to genetic differences in growth potential.

In the U.S., this gradient is small but persistent. For example, the CDC’s Pediatric Nutrition Surveillance System (PedNSS), which monitors growth data from low-income children receiving benefits from the WIC Program (Special Supplemental Feeding Program for Women, Infants, and Children), shows a persistently elevated prevalence of short stature among these low-income children compared to the general U.S. child population, especially among black children, despite a slightly greater growth potential for populations of African descent. [1]

Food insecurity and hunger are persistent problems for poor and near poor populations in the United States.

A measure related to nutritional status is “food security”. The U.S. Department of Agriculture (USDA) defines food security as “access by all people at all times to enough food for an active, healthy life” and household food insecurity to mean “that a household had limited or uncertain availability of food, or limited or uncertain ability to acquire acceptable foods in socially acceptable ways (i.e., without resorting to emergency food supplies, scavenging, stealing, or other unusual coping strategies). Food-insecure households are worried or unsure whether they would be able to get enough to eat, and most reduce the quality, variety, or desirability of their diets. They may resort to emergency food sources or other extraordinary coping behaviors to meet their basic food needs.”2

Food security is measured using an 18-item questionnaire developed by the U.S. Department of Agriculture and the National Center for Health Statistics. The questionnaire also allows for an estimate of hunger in households, defined by the USDA as “involuntary hunger that results from not being able to afford enough food” as opposed to, e.g., hunger due to dieting to lose weight, fasting for religious reasons, or being too busy to eat. Scaling of household food insecurity and hunger is possible because families tend to behave in a common manner when faced with insufficient resources to obtain food. These are shown in Table 1

Table 1: Responses of Food Insecure families

Supplement food supply by borrowing from friends or family (e.g. sending children to a relative’s home for meals)

Rely on “emergency food” providers

Shift purchasing pattern to obtain less expensive, more filling foods at the lowest cost .

Adults reduce portion sizes and/or skip meals to ensure that the children to have enough to eat

Reduce the children’s portion sizes,

In the most extreme cases, children miss meals along with the adults

TEACHING CAPTION: Food insecurity is graded according to how far down this list families have to go to feed their children. Levels 1 and 2 represent food insecurity. By levels 3 and 4, the quality of the family’s diet is affected. At levels 5 and 6 children are hungry and malnourished.

The most recent data available show that the prevalence of food insecurity increased from 10.7 percent of U.S. households in 2001 to 11.1 percent (12.1 million households) in 2002, and the prevalence of food insecurity with hunger increased from 3.3 percent to 3.5 percent (3.8 million households). Children were hungry at times during the year in 265,000 households (0.7 percent of households with children) because the household lacked sufficient money or other resources for food. [2]

Case Study 1: Andre W.

You see Ms. W and her one-year-old child Andre in your continuity clinic for a routine health visit. This is your first visit with this family, whose prior primary care clinician, another resident, has just graduated. You note from the record that Andre missed his 9-month health maintenance visit, and that Ms. W is a single parent and has two older children, age 6 and 9 years, who are both in school. She works full-time as a clerk in a local pharmacy and leaves Andre with a babysitter while she is working. You also note that Andre was tracking along the 25th percentile of weight-for-age at the time of his last visit, and the measurements obtained today put him just below the 5th percentile of weight-for-age. A history and physical exam do not suggest any “organic” reason to account for Andre’s failure-to-thrive.

Q1. What else do you need to know to assess Andre’s condition?

A1. While there are certainly “organic” problems that may not be evident on history and physical exam, and might be suggested by a screening laboratory evaluation (e.g., renal tubular acidosis, lead toxicity), there are many “non-organic” factors which could affect Andre’s growth. Perhaps an interactional feeding disorder has developed. Perhaps he is not receiving adequate care from the babysitter. And it is also possible that the family has food supply problems, i.e. food insecurity, which has affected Andre’s dietary intake.

Q2. How do you assess the family’s food supply?

A2. A simple, direct question usually suffices, e.g. “do you always have enough to feed yourself and your family the kind of food that you need? Do you sometimes not have enough?” These are the first questions in the USDA food insecurity questionnaire.

You also want to know Andre’s typical dietary intake. In the primary care visit a food frequency can be helpful. Ask Ms. W to tell you what she feeds Andre on a typical day (and what he gets at the babysitter’s, if known); it is usually possible to estimate quantities of milk, formula, and juice intake.

TABLE 2 - A simplified food frequency questionnaire

How many cups/bottles of milk does “Andre” take in 24 hours?

* also ask what kind of milk is used

How many cups of juice does “Andre” take in 24 hours?

Does Andre have a mix of foods: Specify meat, dairy products, fruit vegetables, cereals and bread? Yes or no

* Ask slowly and watch parent for hesitancy. Follow-up on your question.

Does Andre have soda, cookies and chips? Yes or no

* A yes answer calls for a follow up of “how often”

Does Andre take a vitamin supplement? Yes or no

* A yes calls for :”what kind”

TEACHING CAPTION: This is a simplified screening. Look for over use of milk or juice, a restrictive diet and overuse of “junk” food. A dietician can be very helpful in following -up on children with inappropriate or overly restrictive diets.

Ms. W replies that “sometimes we don’t have enough for everybody, so sometimes I cut down on how much I eat, but I always make sure that Andre has enough to eat.” His diet consists of formula (32 oz/day) and table foods.

Q3. Is the W family food insecure? How might this be affecting Andre’s diet?

A3. While you have not administered the USDA Household Food Security Questionnaire, which defines food insecurity, Ms. W’s response that “sometimes we don’t have enough for everybody” identifies this household as one that is most likely food insecure, and her reporting that she sometimes reduces her own intake to protect the children’s food supply implies that this is a household experiencing hunger.

The USDA Questionnaire is shown in Appendix 1; simply stating “Sometimes we don’t have enough food...,” however, should trigger a referral to a social worker, dietician and a food or income support program

Mrs. W is probably using various coping strategies, which might include the purchase of foods which provide the most filling diet at lowest cost, at the expense of nutrient density. This pattern is known as the “Engels phenomenon", first described amongst the working class of the Industrial Revolution of mid-18th century England.

FIGURE 1 -The Engels’ Phenomenon

CAPTION: Note that the rise in expenses for essentials rises 1 to1 with income to the poverty level. Once past the poverty level, the % of income spent on necessities levels off leaving increasing amounts of income for discretionary spending

An extension of the Engels' phenomenon is “As income falls or food costs rise, food selection narrows to those items providing most energy at lowest cost. If these conditions persist, essential nutrients diminish in the diet and malnutrition ensues”

As is apparent from widely differing studies in the United States, rising food costs, falling income, increased costs for rent, heating apartments in the winter, or even an additional expenditure of $50 a month for a broken water heater can trigger the Engels’ phenomenon. As will be shown, supplemental food programs are remarkably effective in reversing this effect.

CASE Study continues

As expected, on closer questioning about the family’s diet, you learn that Ms. W has been relying on rice, potatoes, and beans for many meals. She mashes this up and feeds it to Andre as well. She occasionally buys meat, but does not have a blender or grinder to puree for Andre. Prepared Baby food in jars is “just too expensive to give him every day”.

Q4. Ms. W says she works full-time. Why can’t she afford a better diet for her family?

A4. Here is a typical income and expense ledger for a `low-wage worker’ such as Mrs. W. She makes minimum wage at her job which, in your state as in most states, is the same as the national minimum wage, $5.15/hr, providing her with a monthly gross income of $824. She receives no child support from either of the two men who fathered her three children, though Andre’s paternal grandmother cares for him while she works. She pays $740/month for her one-bedroom apartment, which includes heat but not electricity or phone. She has been on the waiting list for subsidized housing vouchers (“Section 8”) for two years; if she were able to get a voucher, and could find an apartment whose landlord would accept it, her rent payments would be fixed at about $250. She admits that she often sends her older boys to a cousin’s house for meals on the weekends; she visits the food pantry at the church in her neighborhood but can only get food there once every two weeks; she is trying to pay off accumulated electric bills; and sometimes has to borrow cash from friends.

Edin and Lein have shown that families dependent on welfare spend 92.4% of a substantially lower income on essentials. Their study 3 of 214 welfare reliant and 165 wage-reliant single mothers found the total monthly expense were $876 and $1,243 respectively. Wage-reliant mothers had hourly incomes of eight dollars or less. Welfare mothers had expenses exceeding their monthly income even with undeclared work included in the analyses. The difference made up by in-kind gifts (e.g., clothes and meals from friends charity).

Of note, Edin and Lein found that neither welfare nor wage-reliant mothers achieved any sufficient level of discretionary income. The arguments for work-reliant policies have much to be said that is positive in terms of achieving a sense of self sufficiency. The macro-social responsibility for those promoting this policy is to ensure a “living wage”. That is, the sum of wages plus non-welfare support – earned income tax credit and supplementary food and housing programs – should allow the opportunity to make free choices. That failure to achieve income security and discretionary income may be a link to the obesity epidemic most predominant in those with incomes at poverty levels and just above. Attempts to live within a minimum wage job are certain to lead to food insecurity or, at the lowest income levels, the “Engels’ phenomenon” and malnutrition.

Q5. What food resources might Ms. W receive to improve the family’s food supply?

A5. Part of your assessment (whether completed by you, a social worker, a nurse, or another staff member) should include Ms. W’s current participation in, knowledge of, likely eligibility for, and desire to participate in food supplement programs. These would include the following (see also Appendix 3):

Q6. What is the impact of the impact of limited income on micronutrient intake?

A6. As noted, healthier diets are substantially more expensive. They fall to the right of the spectrum of an energy content versus cost on the graph developed by Drewnowski (figure 2a.) --an indirect relationship. By contrast, the folate content of foods correlates directly with cost with few exceptions. Thus, to obtain the Recommended Daily Allowance of 400 micrograms of folate, one has to either consume multiple servings of high energy density cheap food or spend substantially more on vegetables. This is shown in Figure 2b. , a modification of the figure provided by Drewnowski. These data suggest that income poverty contributes to micronutrient deficiencies and obesity concomitantly.

FIGURE 2a. - Drewnowski's graph

FIGURE 2b. - Micronutrient and energy content versus food costs for a variety of foods

TEACHING CAPTION: Folate content and cost are highly and significantly correlated (r2 = + 0.7; p < 0.0001) The relationship between energy content and cost is also significant (r2 = -0.39; p = <0.0489).

(Derived by R. Karp and A. Chogle from Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004; 79: 6-16.)

Program Eligibility

What it provides other information Food Stampsgross household income of 130 percent or less of the Federal Poverty Level ($24,505 per year for a family of four in 2004)There is relatively free choice of foods so long as they are not imported or prepared for consumption. The imported rule has been relaxed, but one can not buy a sandwich and a drink on Food Stamps. No tobacco, alcohol, or non-food products are permitted. There are limits on assets. Most documented immigrants who have lived in the U.S. for at least 5 years are eligible; for children this requirement is not WICPregnant or lactating women and children birth to fifth birthday, with family income less than 185% of Federal Poverty Level; priority levels, ranging from, e.g. failure-to-thrive (high) to inadequate dietary pattern only (low) Funding for WIC Is set to limit participation to about ? of eligible childrenWIC is a prescription food program where the “medication” is a specific list (item and quantity) of food necessary for infants and toddlers WIC services are integrated into primary health care . This keeps WIC children up to date with immunizations and ensures that they are screened for CBC and lead poisoning. To date there are no restrictions based on immigration status. School Meals Progams:

National School Lunch Progam

School Breakfast ProgramChildren whose families’ incomes are below 130% Federal Poverty Level are eligible for free meals; those with family incomes between 130 and 185% poverty are eligible for reduced-price meals. When a sufficient percentage of the school children in a community live below the poverty level, the means testing – a sure way to keep kids from signing up – may be waivedThere are National School Lunch programs in almost every high need community. Breakfasts are available in some. All students in participating schools are eligible regardless of immigration status. The emphasis has been on getting enough food to hungry children. The obesity epidemic has caused concern for the content. Also, self prepared meals have almost disappeared from NSLPs because of the decreased cost (unfortunately quality, too) of highly lucrative prepackaged contracts for suppliers.Summer Feeding ProgramAgencies - camps for disadvantaged children, emergency shelters, etc. – can get commodities purchased as part of farm support programs These are summer programs and support for commodity provision. Other emergency programs are available. See Nestle, M (in) Karp, 1993 for a complete listing) These are often discouraged because they have the feel of “bread lines.”Many agencies are eligible. It is always worth looking for support for food programs to support worthwhile projects.

Figure 3. -Reversing the Engels’ Phenomenon:

Explanation (see Malnurished Children in the United States pg. 188)

Supplemental food programs work in two ways. First, they provide nutritious food. Second, they relieve parents of the need to purchase food. The additional income is, for the most part, used to increase the quality of foods purchased. A third benefit is that these programs enhance the integration of poorer families into the mainstream of American society.

The most effective way of ensuring nutritious food to the poor is through current supplemental food plans -- WIC, National School Feeding, and Food Stamps. These programs work in two ways. First, the foods provided are of a high nutritional value. Second, the family is relieved of the responsibility of purchasing a substantial part of their daily caloric need. This increases the nutrient value of the remaining part of the daily diet and equalizes nutrient intake to that of middle income families. Moreover, there is great advantage to be gained when poor families and communities are able to appreciate concern rather than neglect from society-at-large.

With all major federal food assistance programs - WIC, National School Meals, and Food Stamps - families use the extra money to purchase food with a higher nutritional value than would be possible otherwise. There is little or no substitution of non-food items with the money saved from the food budget, as suggested by some critics. These food programs are not "welfare handouts." Rather, they are essential to the well-being of working families who cannot afford the essential goods and services that they produce or provide. These programs are a form of income support that helps bring working poor families out of poverty.

You ask Ms. W about her participation in these programs. She responds that she gets WIC for Andre, and that her two school-aged children both receive free school breakfast and lunch. She does not receive Food Stamps because she has trouble getting the time off her job to complete the application process, and she thinks she wouldn’t get that much in food assistance anyway. Using the Web-based tool referenced above, it appears that Ms. W may be entitled to ~$420/mo. in Food Stamp benefits. She accepts your staff social worker’s offer of assistance to complete the application process.

You return to Andre’s dietary history, and ask specifically about his formula intake. Ms. W reports that she hasn’t given him any whole cow’s milk, since her prior pediatrician had advised against it, and that she prepares bottles from the powdered formula that she obtains from the WIC program when she sends him to his grandmother’s house. She admits that she usually “stretches” the powder “so it’ll last the whole month.”

1. Andre receives WIC benefits, including formula. Why is Ms. W diluting his formula?

WIC is a supplemental nutrition program and is not intended to provide adequate nutrition for an entire month. The formula Ms. W receives for Andre would last only about three weeks, and is expensive to purchase: a 28.5 oz can of powdered formula might cost $24 or more, and would last Andre less than a week. This represents about one-third of the cash Ms. W has left from her wages after she pays her rent.

You explain to Ms. W that Andre’s diet is not sufficiently dense in food energy, and you advise her about the importance of diluting Andre’s formula properly, but as he is a year old now you suggest she switch to whole cow’s milk. You stress the importance of high-calorie, nutrient-dense foods for Andre, and that her getting Food Stamps could be very important for her family. The social worker gives Ms. W a list of sites sponsoring the Summer Feeding Program where her older children can get a free lunch during the summer months as well as a list of emergency food sources in her neighborhood.

III.) Iron deficiency

Question: is iron deficiency more common amongst low-income children? Why is this important?

The most common micronutrient deficiency in the U.S., and worldwide, is iron deficiency, which in children is associated with developmental delays and behavioral disturbances, which may be long-lasting. Iron deficiency is also associated with lead toxicity, as the gut increases its absorption of both iron and lead in the iron-deficient state. Iron deficiency is much more common amongst low-income children than amongst children who are not poor; in the 2002 PedNSS, the prevalence of anemia was 13.1%, compared with 2.8% for U.S. children less than 5 years of age, and was 19% for black children.1 Similarly, the low-income pregnant women monitored by the CDC’s Pregnancy Nutrition Surveillance System (PNSS) have high rates of anemia: 29% (and 44% among black women) during the third trimester.4

Case Study 2: Alisha P.

Your next patient is Alisha P, a ten-month old girl here for a routine health maintenance visit. She has an unremarkable past medical history. Mother reports no food supply problems. She breast-fed Alisha for one month, then switched over to formula. She gives Alisha iron-fortified formula which she gets from WIC program vouchers, and a varied diet of baby foods and some table foods including French fries and cooked carrots. Alisha appears healthy, has normal growth parameters, and a normal physical exam. You send a blood sample for a screening CBC and lead test. The CBC comes back with a hemoglobin of 9.2, a hematocrit of 27, an MCV of 62, and an RDW of 18.3.

1. Why is Alisha anemic?

Alisha’s CBC parameters are most consistent with iron deficiency: a microcytic anemia with greater-than-normal variation in red cell size (elevated RDW). The other possibility is lead toxicity, which will be excluded by a normal venous (or capillary) lead level. Her iron deficiency most likely results from inadequate intake, although blood loss is also possible.

2. What are the major sources of iron in Alisha’s diet?

For the first six moths of life, a normal term infant can maintain adequate iron stores from breast milk and/or iron-fortified formula. After this time, additional dietary sources of iron are required, including iron-fortified cereal and other food sources. Iron from vegetable sources (non-heme iron) is more poorly absorbed than iron from meat sources (heme iron); heme iron also promotes the absorption of non-heme iron, as does Vitamin C.

A careful dietary history reveals that Ms. P only began giving Alisha meat in the past few weeks, since she thought the best way to introduce foods was to give her fruits first, then vegetables, then meats. Remembering Andrew W, you ask Ms. P what she gives Alisha when her WIC coupons for formula run out. She tells you that she gives Alisha “Carnation” formula when she runs out of the WIC formula.

3. What are the dietary factors contributing to Alisha’s iron deficiency?

The "Carnation" ® formula Ms. P refers to has been used as a substitute for more expensive commercial infant formulas. Carnation evaporated milk is appropriate for use as whole milk past one year of age. Before then it is not. It is usually made by diluting canned evaporated milk with an equal volume of water, and then adding two or three teaspoons of corn syrup to an 8-ounce bottle. While this is tolerated by most infants, the mixture contains virtually no iron. Furthermore, calcium and phosphate ions in milk form insoluble complexes in the gut with iron from other dietary sources and inhibit its absorption. If Ms. P had been substituting whole cow’s milk for formula, occult blood loss from the gut may also have contributed to Alisha’s iron deficiency.

IV.) Overweight

Question: is overweight more prevalent among minority children and youth than among whites?

Yes. Data from the National Longitudinal Survey of Youth (NSLY) show that in 1988, rates of overweight (BMI/age >95th percentile) were similar for black, Latino, and non-Latino white children age 4 to 12 years; by 1998 these rates had increased by 50% (to 12.3%) for white non-Latino children, and by 120% (to 21.5% and 21.8% respectively) for black and Latino children.5 Data from the National Health and Nutrition Examination Survey (NHANES) from 1999-2002 show that overweight rates among children age 6 to 19 years for whites, blacks, and Mexican-Americans were, respectively, 14.3%, 17.9%, and 25.5% for boys, and 12.9, 23.2, and 18.5% for girls.6

Question: is income related to overweight prevalence among U.S. children?

Yes, but the effect varies by race. The NSLY study found that overall, high income was protective of overweight among whites, equivocal among Hispanics, and associated with increased rates of overweight among African-Americans.5

Case Study 3: Veronique L.

You see five-year-old Veronique L and her mother Ms. L for a routine health visit. This is her first routine health visit in two years. Ms. L tells you that Veronique has been well and since her shots were all up to date, she didn’t think there was any need to see you, but now she needs more shots for school. Her past medical history is unremarkable. Veronique lives with her mother; her father and older sister are in Haiti, from which Veronique emigrated with her mother when she was one year old. Her physical exam is normal, but her weight is 23 kg and her height is 105 cm

1. Is Veronique overweight?

Yes. Her BMI is 20.86, which represents the 99th percentile of BMI/age, equivalent to a z-score of 2.51 (i.e., 2.51 standard deviations above the median BMI/age).

2. How do you begin to assess the etiology of her overweight?

A thorough history, as usual, is the place to begin. This should include a past and current history of Veronique’s nutritional status and dietary pattern. In addition to diet, other factors which contribute to overweight in children include physical activity and television watching.

In response to your questions, you learn from Ms. L that Veronique was breast-fed for her first year of life, and given foods such as porridge and soup by age 6 months. She was a skinny baby and had several episodes of diarrhea before arriving in the U.S.

There is evidence, e.g. from studies of the survivors of the Dutch famine of 1944, that prenatal maternal undernutrition may predispose to obesity in the later life of the child, giving rise to the concept of in utero “metabolic programming”, although this remains to be proven. There is evidence that this effect may also occur with malnutrition in early infancy. These may or may not be factors in Veronique’s case. However, it is likely that Ms. L’s life experience, growing up and raising children in a poor country, has led her to believe that a child’s looking fat is a sign of good health. It is important to elucidate this factor and work toward helping Ms. L understand the nature of healthy and unhealthy body habitus. This can be approached through a careful dietary history.

Ms. L explains that she has always fed Veronique “legume”, a vegetable stew which she makes with butter. In Haiti she couldn’t get very much butter or oil, but here in the U.S. she can buy a pound of butter for the equivalent of twenty minutes’ of her work as a maid at a big hotel, so she uses at least a half-stick a day in preparing Veronique’s meals. She is pleased that Veronique looks so healthy. Further dietary history reveals that Veronique drinks three to four glasses of juice on an average day. She gets little exercise outdoors because her mother feels the neighborhood is not safe. She watches a lot of TV, perhaps 4 hours on an average weekday.

It is not surprising that Veronique is overweight. She is being fed a very high calorie diet at mealtimes. Her consumption of juice probably adds to her energy imbalance, since there is evidence that mono-, di-, and oligosaccharides do not contribute to satiety when consumed in solution, as opposed to their being consumed in solid form, and each 8-ounce glass of juice adds 100 calories or more to Veronique’s daily intake. From the standpoint of energy balance, juice and soft drink consumption are probably equivalent, and soft drink consumption likely contributes to the obesity epidemic, having increased two- to three-fold among U.S. children in the past 20 years; recent data implicate soft drink consumption directly in childhood overweight,7 and a successful intervention in schools which resulted in a reduced prevalence of overweight has been reported.8 Watching television exacerbates Veronique’s problem, as television viewing has been associated with childhood overweight, an effect that is likely mediated not only by inactivity but also by the child’s being exposed to advertising. The average child in the U.S. sees some 20,000 TV ads each year, about half of which are for food and beverages; the U.S. food industry targets some $12.7 billion annually on advertising aimed at children. The pervasiveness of advertising to children, especially on television; the abundance of high-fat, high-calorie fast food and snacks; and the lack of opportunity for physical activity, e.g. in school, all contribute to the “toxic environment” for children in the U.S.9 And, crucially, Ms. L does not perceive Veronique’s weight as a problem, but rather as a sign that she is not going to be sick from undernutrition.

3. What is Veronique’s risk for becoming an overweight adult?

Her risk is high. A longitudinal study at a large HMO found that 52% of children whose BMI/age was at or above the 95th percentile went on to become obese in young adulthood. This risk rises to ~80% for children with BMI/age > 95th percentile in the late teen years.10

You begin by explaining to Ms. L why you are concerned with Veronique’s weight: that she is at high risk for developing many serious medical conditions if she continues through childhood and adolescence with this degree of overweight. Your goal at this point is not to implement sweeping changes in the family’s lifestyle but rather to move the mother toward an understanding of the basis for your concern. You suggest one change that she could try between now and your next visit, perhaps to reduce the volume of juice consumption, or the time spent in front of the TV. You arrange to see the family again soon, perhaps in a month or two, both to monitor Veronique’s BMI/age and, most importantly, to continue to impress upon the family your concern, and to try different approaches to promoting change. This might include a referral to a dietician and an exploration of opportunities for physical activity that might be incorporated into the family’s routine.

Summary

Low-income infants, children, and youth in the U.S. are at high risk for adverse nutritional outcomes, including undernutrition (failure-to-thrive and iron deficiency) and overnutrition (overweight). Both economic and cultural factors contribute to this nutritional morbidity. Poor families have insufficient resources to afford a healthful diet; food assistance programs offer well-documented benefits to needy families, but even with maximal participation, food sufficiency often cannot be achieved, especially for families whose sole income comes from public assistance. Survival strategies of obtaining the highest number of calories at the lowest cost can lead to overweight, especially among near-poor families, and those emigrating from poor countries with a history of widespread child undernutrition. An appreciation of these forces, and of the existing food assistance programs and how to access them, is essential for pediatric clinicians attempting to address comprehensively the well-being of their patients.

REFERENCES

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Annotated Answers:

A1. The answer is B. Obesity in childhood is most common for those living at the cusp of poverty and sufficiency. This a point at which discretionary income first appears.

A2. The answer is C. It is often assumed that money is ill spent by poor families or diverted from providing essentials. While undoubtedly this occurs. The choice of high fat foods is wise in the context of poverty.

A3. The answer is A. This is a question whose answer has changed over the past 6o years. Earlier texts will inform you that heredity predominates. The growth of Japanese Americans provide the best illustration of how a change in environment can affect growth in sequential generations.

A4. The answer is C. The explanation here is an extension of the anser to Q2. Careful evaluations of supplemental food plan expenditures suggest that extra money, when available, is spent on essentials.