1. What’s a Child Nutrition Program? Subsidized Housing and the Low- Income Home Energy Assistance Program (LIHEAP) Are Linked to Improved Growth Outcomes for Young Children of Color Stephanie Ettinger de Cuba, MPH Children’s Sentinel Nutrition Assessment Program (C-SNAP) Boston University School of Public Health Boston Medical Center Tuesday, November 7, 2006

2. Authors Stephanie Ettinger de Cuba, MPH Deborah A. Frank, MD Nicole Neault, MPH Mariana Chilton, PhD John Cook, PhD Carol Berkowitz, MD Maureen Black, PhD Patrick Casey, MD, MPH Diana Cutts, MD Alan Meyers, MD, MPH Nieves Zaldivar, MD Suzette Levenson, MPH, EdM Timothy Heeren, PhD Zhaoyan Yang, MS

3. Children’s Sentinel Nutrition Assessment Program (C-SNAP) A national network of clinicians and public health specialists for research in multiple pediatric settings on the effect of U.S. social policy on young, low- income children’s health and nutrition.

4. C-SNAP Study Sites -Little Rock, AR-Boston, MA-Washington, D.C.* -Baltimore, MD-Minneapolis, MN -Philadelphia, PA-Los Angeles, CA* C-SNAP Study Sites

5. Study Objective Evaluate the importance of federal assistance programs not commonly identified with child nutrition, such as LIHEAP and Subsidized Housing, to child growth and health outcomes among young black and Latino children

6. Study Methods August 1998 – December 2004 Sentinel sample Interview caregivers Children 0-3 years Emergency departments & acute care clinics Black and Latino children - over 80% Weight & length measurements -- outcome of interest & accepted international indicator of wellbeing

7. Eligible Families Sample restricted to: –Low-income renters of color with children under 3 –Participate in at least one means-tested program Subsidized Housing sample: (n = 13,069) LIHEAP sample: (n = 4,091) –additionally: Excludes private insurance Only renters - heat not included

8. Analytic Methods Multiple logistic regression Covariates for each program separate - depending on correlation with program/outcome

9. Subsidized Housing analyses controlled for: Mother born in US Receipt of TANF Receipt of WIC Food insecurity status

10. LIHEAP analyses controlled for: Mother born in US Year of interview Food insecurity status Receipt of either TANF or Food Stamps Receipt of WIC Receipt of Housing Subsidy Caregiver marital status Caregiver employment

11. 2004 Poverty Rates Among Households with Children US Census Bureau, 2005 Poverty Highest among black and Latino families

12. 2004 Food Insecurity Rates among Households with Children Nord, Andrews, and Carlson, 2005 Food insecurity highest among black and Latino families

13. 2004 National Eligible Household Participation in LIHEAP U.S. Department of Health & Human Services, 2004

14. Housing & LIHEAP only reach a fraction of eligible C-SNAP families

15. Subsidized Housing Helps Black Children Grow OutcomeSubsidy (n=3,116) No Subsidy (n=4,977) P Value ≤2 SD Weight/Age below the mean 1.001.33P = 0.006 OutcomeSubsidy (n=3,116) No Subsidy (n=4,977) P Value Mean Z- Height/Age Z = 0.134Z=-0.005P<.0001

16. LIHEAP Improves Young Black Children’s Growth OutcomeLIHEAP (n=778) No LIHEAP (n=3,313) P Values At Nutritional Risk for Growth Problems* 1.001.29P = 0.05 OutcomeLIHEAP (n=778) No LIHEAP (n=3,313) P Values Mean Z- Weight/Age Z = 0.061Z=-0.051P =.04 *Nutritional risk: < 5 th percentile for weight-for-age or <10 th percentile for weight-for-height

17. Subsidized Housing Helps Latino Children Grow OutcomeSubsidy (n=720) No Subsidy (n=4,256) P Value ≤2 SD Height/Age below the mean 1.001.99P = 0.02

18. LIHEAP and Latino Children Results for Latino children and LIHEAP not presented since did not reach statistical significance, probably due to small sample size. Limited program participation reflects sample characteristics –most Latino children lived in California, where few families of any ethnicity access LIHEAP.

19. Overweight? No associations between overweight and LIHEAP or Subsidized Housing

20. Limitations Interviews in English, Spanish, and Somali (MN only) Only blacks and Latinos Exclusion of the most severely ill or injured children Associations are not causation Difficult to make national extrapolations

21. Non-food assistance programs can improve children’s growth Programs like LIHEAP and Subsidized Housing linked to improved growth outcomes “Heat or eat” phenomenon: Food budget only variable expense Food most easily decreased to pay for other expenses, leading to increased food insecurity, particularly during winter months.

22. Implications for Young Black & Latino Children Growth is indicator of health in young children Adverse child growth outcomes associated with not receiving benefits Safety net programs buffer young children from effects of poverty

23. UN Convention on the Rights of the Child Article 27 1.States Parties recognize the right of every child to a standard of living adequate for the child’s physical, mental, spiritual, moral and social development… 3. States Parties… shall take appropriate measures to assist parents…to provide material assistance and support programmes, particularly with regard to nutrition, clothing and housing.

24. Why does it matter? Housing and Energy are Health Issues:  Early growth failure sets children up for long-term health & development problems.

25. Affordable Housing and Energy are Human Rights Issues:  Black & Latino children => 35% of all children in US.  Black & Latino children higher risk for living in poor HHs  Also at greater risk for negative growth effects associated with poverty and food insecurity.  Food insecurity and its effects exacerbate achievement gaps and deepen racial/ethnic health disparities, depriving victims of other rights. Society Has a Duty to Guarantee Children’s Basic Rights:  Macro perspective: Denial of basic rights -> disastrous effects on workforce participation and health of national economy. Why does it matter?

26. What can we do about changing policy? Educate Policymakers to: Reconsider standard view of which assistance programs influence child nutrition. –Food + Non Food = Optimal Child Health Understand that safety-net programs “good medicine” but dosage and availability inadequate. Stop cutting or freezing funding for safety-net programs - created health crisis for poor children, especially children of color Give recommended “dosage”: Full package of benefits -> social investment -> reduction of racial/ethnic disparities

27. Acknowledgements Report sponsored by the Joint Center for Political and Economic Studies Thanks to Avi Perry, Bill Emerson National Hunger Fellow, for his assistance in preparing this presentation. C-SNAP operations and analyses have been supported by: the Abell Foundation, the Annie E. Casey Foundation, the Anthony Spinazzola Foundation, the Candle Foundation, the Claneil Foundation, the Daniel Pitino Foundation, the EOS Foundation, the Gold Foundation, the Gryphon Fund, the Hartford Foundation for Public Giving, Jennifer Kaminsky, MAZON: A Jewish Response to Hunger, the Minneapolis Foundation, the New Hampshire Charitable Foundation, Project Bread, the Sandpiper Philanthropic Foundation, the Schaffer Foundation, Susan P. Davies and Richard W. Talkov, Susan Schiro and Peter Manus, the Thomas Wilson Sanitarium for Children of Baltimore City, the United States Department of Agriculture, Vitamin Litigation Funding, with major funding from the W. K. Kellogg Foundation.

28. Please visit us on the web: www.c-snap.org Thank you!