INSTITUTE OF MEDICINE AS A PROFESSION: Physician Advocacy Conference November 18-19, 2010

1. INSTITUTE OF MEDICINE AS A PROFESSION: Physician Advocacy Conference November 18-19, 2010 Dr. Deborah A. Frank Professor of Pediatrics, Boston University School of Medicine Founder and Principal Investigator, Children’s HealthWatch Founder and Director, Grow Clinic for Children, Boston Medical Center

2. WE SIT BESIDE THE GIANTS ON WHOSE SHOULDERS WE STAND

3. How Did I Get Here?

5. You were Either Hospital or Orphanage

8. How Did I Get Here?

9. Riding Two Advocacy Horses

10. Trouble with Women is They Take Everything Personally!

11. Children’s HealthWatch Collect datain five urban, safety-net hospitals Produce scientific research that is original and timely Share evidence with state and national partners to inform policy choices

12. 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)

13. Why Watch Children Birth to 3?

16. 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)

17. 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

18. Help Connect the Dots

19. FOOD INSECURITY, HUNGER, AND MALNUTRITION ARE ALL • Child Health Issues • Adult Health Issues • Mental Health Issues • Educational Issues • Political Issues • Moral Issues

20. CHANGES IN FAMILY SURVIVAL RESOURCES RAPIDLY REFLECTED IN HEALTH, LEARNING, AND GROWTH OF YOUNG CHILDREN

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

24. 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

25. Real Cost of a Healthy Diet Can parents afford to purchase healthy food? $1.33 $2.79 Stop and Shop Price Check Sept 2010 880 calories 880 calories Drewnowski 2004 Tight budgets limit food choices; cheap calories provide little nutritional value. 25

27. 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

28. GROWN UP BRAINS NEED NUTRIENTS TOO brain

29. Help Connect the Dots

30. 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

31. Effects of Energy Insecurity Comparedwith 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

32. Housing Insecurity Household is overcrowded, doubled up with another family and/or has moved twice or more in the last year

33. Effects of HousingInsecurity 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

34. Housing Insecurity Food Insecurity Energy Insecurity Economic Hardship

35. Scoring: Cumulative Hardship Index • Score of 0, 1, or 2 for each hardship 0= Secure 1= Moderately insecure 2= Severely insecure • Total possible score of 6 0= No Hardship 1-3= Moderate Hardship 4-6= Severe Hardship

36. 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

37. What Do We Mean by Child Wellness? • Good or excellent health • No hospitalizations • Not at developmental risk • Not overweight or underweight

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

39. 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

40. 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

41. 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

42. Can We Fix It?

43. Emergency Fixes

44. EMERGENCY FOOD NETWORK

45. Is That All That Can Be Done?

46. Fixing Hunger and Hardship Long-Term is a Political Issue

47. Which Programs Promote Healthy Height and Weight? • WIC • CHILDCARE FEEDING • LIHEAP • HOUSING SUBSIDY

48. Which Programs Decrease Poor Health/Hospitalizations? • WIC • SNAP • LIHEAP • CHILDCARE FEEDING

49. Which Programs Decrease Developmental Risk? • SNAP • WIC • HOUSING SUBSIDIES

50. Riding Two Advocacy Horses