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Commonwealth:  A Journal of Political Science       Volume 14, Number 1      December 2008 
Special Policy Issue on Public Health             2008 PPSA/LORL, PA House of Reps.  ISSN 0890-2410 

 

 

 

Evidence That Young Children Are Falling 
Through the Safety Net:  Policy Implications of 

Hunger and Poor Health in Pennsylvania 
 

Mariana Chilton, PhD, MPH, Drexel University  
School of Public Health 

Michelle Chyatte, MPH, Drexel University School of Public Health 
Edward Gracely, PhD, Drexel University College of Medicine 

 
 

Abstract 

Hunger is still lurking in Pennsylvania. But it can be addressed and 
treated by policymakers and legislators. This paper gives an overview of 
the empirical evidence that federal and state policymakers have a direct 
impact on the health and wellbeing of young children through the 
statewide implementation of safety net programs such as the Food Stamp 
Program, Women, Infants and Children Supplemental Nutrition Program, 
and Low Income Heat and Energy Assistance. Food insecurity, known as 
the lack of access to enough food for an active and healthy life, is 
strongly associated with increased hospitalizations, poor child health, 
developmental risk and maternal depression. The Philadelphia GROW 
Project research in Philadelphia demonstrates that food insecurity and its 
negative health consequences are prevalent and damaging to the lives of 
children and their parents in the Commonwealth. The continuing food 
insecurity in Philadelphia and Pennsylvania is having a damaging affect 
not only on the wellbeing of young children, but also on the purse strings 
of Pennsylvania. Policymakers and legislators have the opportunity to 
turn this trend around with sound, evidence-based decision making as 
they carry out their legislative agendas. We end this paper with 
recommendations for how key decision-makers can have an immediate 
and lasting impact on improving the lives of low-income families with 
young children.  

 



56 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

Introduction 

Despite the existence of federal and state nutrition programs, hunger 
is still lurking in Pennsylvania. But it can be addressed and treated. One 
cannot see hunger with the naked eye, and it may not even manifest as 
underweight or overweight, but it does have very tangible effects on the 
body, the psyche, emotional wellbeing, and developmental potential of 
children and adults. The U.S. Department of Agriculture (USDA) 
developed a term more than a decade ago to capture this non-visible but 
harmful form of food deprivation. This term is “food insecurity.” Food 
insecurity is the lack of access to enough nutritious food for an active 
and healthy life due to economic constraints (Nord et al. 2007). Food 
insecurity is particularly dangerous for infants and toddlers because 
children are in the critical stage of neurological, social, and physical 
development during their first three years (Shonkoff 2003). Even the 
slightest interruption in nutritional intake can derail short and long-term 
development (Chilton et al. 2007; Cook and Frank 2008; Rose-Jacobs et 
al. 2008; Walker et al. 2007). In turn, this can cost the United States’ 
health and education system billions of dollars (Brown et al. 2007). The 
human suffering and the economic burden of food insecurity deserve 
greater attention from policymakers and legislators. There is now up-to-
date research that can be utilized for evidence-based decision-making to 
prevent food insecurity and poor health in the years to come. 

Legislators and policymakers can intervene to address household 
food insecurity through sound legislation and administrative actions that 
support low-income families in multiple ways that go well beyond food 
assistance programs and food program set asides. This paper describes 
how household food insecurity is associated with increased rates of 
reported fair and poor health, with higher rates of developmental risk 
among Pennsylvania infants and toddlers, and with greatly increased risk 
of maternal depressive symptoms. Maternal depressive symptoms are 
important to consider as they have powerful effects on the health and 
development of the child, as well as the earning potential of mothers.  
We review the research on these issues, explain the ongoing research 
from the Philadelphia GROW Project, and we describe policy 
recommendations that call for increased attention to income support 
programs such as Food Stamps, Temporary Assistance to Needy 
Families, and Medicaid, as well as deliberate and sustained action to 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         57 
 
 
 

 

continue to recognize and treat families with young children at risk for 
food insecurity. 

The most up-to-date work on household food insecurity research in 
Pennsylvania, and the basis of these results and policy recommendations, 
comes from the Philadelphia GROW Project (www.growproject.org) 
which works with parents, scientists, and policymakers to improve early 
childhood nutrition and to prevent food insecurity among very young 
children and their families. Our work is coordinated among three 
endeavors: 1) The GROW Clinic, a multidisciplinary clinic for children 
with failure to thrive, or undernourished children; 2) The Children’s 
Sentinel Nutrition Assessment Program (www.c-snap.org), a national 
multi-site research study that investigates the impact of public policies on 
the health and wellbeing of young children; and 3) Advocacy related to 
both research and clinical service.   

We suggest that each major city in the Commonwealth develop their 
own project similar to the GROW Project so that: 1) All children with a 
diagnosis of clinical undernutrition are provided with best practice, fully 
reimbursed multidisciplinary treatment; so that 2) Each city tracks, 
responds and seeks to prevent household food insecurity for households 
with young children; and so that 3) both of these areas of activity are 
readily available to translate to policymakers who rely on evidence to 
make decisions. 

Addressing and preventing household food insecurity makes 
economic sense. Household food insecurity has been estimated to cost 
the nation $90 billion a year for increased health-care costs, reduced 
worker productivity, lost educational attainment, and the cost of 
maintaining emergency feeding programs. The State of Pennsylvania 
ranks in the top five states as having the highest expenditures associated 
with food insecurity (Brown et al. 2007). Using legislation and 
policymaking decisions to intervene on household food insecurity will 
not only help to improve the health of children in low-income families, 
but it will also save the Commonwealth significant economic costs. 

 

The Definition and Prevalence of Household Food Insecurity 

Food insecurity, as the lack of access to nutritious food for an active 
and healthy life, contains at least two dimensions of food deprivation.  



58 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

The first dimension relates to the quantity of food (is there enough?); and 
the second dimension includes the concept of adequate food for an active 
and healthy life (is the food of sufficient quality?). The dimensions are 
captured in an 18-point scale, which asks questions about access, 
quantity, and quality of food, and the experience of hunger. Examples of 
the USDA questions are included below in Table 1. 

 
Table 1:  Examples of Food Insecurity Questions 

Relating to Children 
 

“Which of the following statements was true for you in the last 12 months?” 

1) “We relied on only a few kinds of low-cost food to feed our children because we 
were running out of money to buy food.” 

2) “We couldn’t feed our children a balanced meal, because we just couldn’t afford 
that.” 

3) “The children were not eating enough because we just couldn’t afford enough 
food.” 

Previous three items include: “Was that often, sometimes,  
or never true for you in the last 12 months?” 

 
4)  “In the last 12 months, did you ever cut the size of any of the children’s meals 

because there wasn’t enough money for food?” 

5)   “In the last 12 months, were the children ever hungry but you just couldn’t afford 
more food?” 

6)   “In the last 12 months, did any of the children ever skip a meal because there 
wasn’t enough money for food?” 

7)   (If “yes” to previous question) “How often did this happen - almost every month, 
some months but not every month, or in only 1 or 2 months?” 

 

According to the responses in the 18-item interview, households are 
categorized within a specific food security status suggesting varying 
levels of nutritional deprivation. The levels of food insecurity addressed 
in this paper are “Household Food Insecurity” and “Child Food 
Insecurity.” Household food insecurity includes attention to anyone in 
the household, but does not address a particular individual within the 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         59 
 
 
 

 

household. It is therefore a composite measure that captures the minimal 
level of risk for nutritional deprivation.   

Child food insecurity is measured at the individual level, and is often 
considered to be the most severe form of food insecurity. Research has 
shown that parents generally protect their own children from 
experiencing food insecurity or hunger (Nord and Hopwood 2007; 
Hamelin et al. 1999). When the parents can no longer shield their 
children from hunger, the deprivation can have serious consequences as 
it penetrates the protective abilities of the adults in the household. 

The United States government research on food insecurity research 
focuses on food expenditures and “diversion of financial resources” 
(Rose 1999) that go towards such expenses as housing, utilities, and car 
payments (Rose 1999). Thus, food insecurity is strongly correlated with 
income. Food insecurity is also associated with poor nutritional intake 
(Rose and Oliveira 1997).   

Nationally, the most updated research carried out be the USDA 
Economic Research Service reported that in 2006, 11.9% of the United 
States population, or 35.5 million people, had experienced food 
insecurity at some point during the year, and that 17.2%, or 12.6 million 
children lived in households that had reported food insecurity. Racial, 
ethnic and gender disparities in the prevalence rates of household food 
insecurity are a critical concern. Female-headed households have a 
prevalence rate that is three times that of the national average (30.4% vs. 
10.9%) (Nord et al. 2007). Nationally, effects of food insecurity among 
households with children is even more pronounced when race/ethnicity 
are considered. According to the USDA, the prevalence of food 
insecurity in households with children in 2006 was highest among Black 
families with 26.4% of families experiencing food insecurity at some 
point during the year. In the same year, Hispanic families experienced a 
food insecurity rate of 23.8%. These rates are twice the rate of food 
insecurity among white households with children (11.3%) (Nord et al. 
2007). As shown above, households with children are at greater risk for 
experiencing household food insecurity, as the prevalence rates for 
households with children are at least 6% above the national average.  
These prevalence rates and the disparities among these rates of food 
insecurity have not changed since the year 2000. 

 



60 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

Making the Case for Pennsylvania: 
Relationships Between Food Insecurity and Wellbeing 

The overall prevalence rate of household food insecurity in 
Pennsylvania is 13.3% (Nord et al. 2007). This is close to the national 
average. A recent report published by Feeding America shows that in 
Pennsylvania 16.8% of children under the age of 18 lived in food 
insecure households in 2006 (Cook 2007). Stated differently, one in six 
children in Pennsylvania exhibits an increased risk of poor health, poor 
physical development, and limited school readiness because of a lack of 
adequate food.   

The problem of food insecurity is even more pronounced in 
Philadelphia, the state’s largest urban city. It is difficult to get local rates 
of household food insecurity without concerted effort and substantial 
funding to glean a representative sample. The survey instrument that 
measures food deprivation with a very limited measure is the Community 
Health Data Base (CHDB) of the Philadelphia Health Management 
Corporation. The CHDB is a community household phone survey of 
residents in Southeastern Pennsylvania that is carried out every two 
years. It “oversamples” low income and elderly households in order to 
gauge true population levels of health-related information. The survey 
includes only one question taken from the USDA Household Food 
Insecurity Short Form (consisting of six questions) (Blumberg et al. 
1999). The question asked is: “Did you ever have to cut the size of your 
meals because you did not have enough money to buy food?” Responses 
to this question have been used by advocates in the Philadelphia area as 
an indicator for “risk” of food insecurity. For Philadelphia, the 
population-based prevalence rate of food insecurity among all 
households is 13.6%, or 151,200 individuals. For females, it is slightly 
higher, and for households with children, the prevalence rate for 2006 
was 16.5% (Community Health Database 2006).   

Among households with children, the racial and ethnic disparities in 
food insecurity seen at the national level also exist in the Philadelphia 
area, with 22.3% of Latino households with children reporting having cut 
a meal versus 16.5% of black and 10.4% of white households (see Table 
2, following page). 

 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         61 
 
 
 

 

Table 2.  Example Health Characteristics of 
Philadelphia Households with Children 

 
By 200% of Federal Poverty Line and by Status of “Cutting a Meal” 

(Indicator of Risk for Food Insecurity) 
Representative of All Philadelphia Residents 

 
Source: GROW Project Analysis of Community Health Data Base, PHMC, June 2006 

 
All Philadelphians 

Regardless of Income* 
Below 200% Poverty* 

 
Variable 

Did Not 
Cut Meal
N=1100 
84.4% 

Cut Meal 
due to lack 
of Money 

N=203 
15.6% 

P Value

Did Not 
Cut  Meal

N=514 
75.3% 

Cut Meal 
due to lack 
of Money 

N=168 
24.7% 

P Value 

 Race/ethnicity 
 Black 
 Latino 
 White 

 
47.9% 
17.5% 
34.6% 

 
51.2% 
27.1% 
21.7% 

 
 

<.0001^

 
55.3% 
25.9% 
18.9% 

 
53.8% 
30.2% 
16.0% 

 
 

.4710 

 Adult Diagnosed   
 with a Mental   
 Health Condition 

12.6% 21.3% .0010^ 15.6% 22.6% .0360^ 

 Adult was Sick but 
 Did Not Seek Care  
 Due to Cost 

8.1%5 37.2% <.0001^ 9.9% 35.1% <.0001^ 

 Adult Self-Rated   
 Health Fair/Poor 

18.6% 46.4% <.0001^ 26.1% 48.2% <.0001^ 

 * Balancing weights used to determine appropriate population-based percentages 
^ P value indicates that the differences rates are statistically significant at the alpha < .05 

 

Latino and black households are disproportionately burdened by 
food insecurity. This is likely due the disproportionate burden of the 
experience of poverty. When the all-Philadelphia population-based 
sample is restricted only to those living at 200% of the federal poverty 
line and below, the racial and ethnic disparities in risk for food insecurity 
almost disappear; the differences become statistically insignificant.  
Among low-income families, the rates for whites, Latinos and blacks 
hover in a common zone between 21% and 27%. In summary, there are 
disparities by race and ethnicity among all of the households with 



62 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

children at risk for food insecurity in Philadelphia and nationally due to 
the higher overall prevalence poverty among African American and 
Latino households. Overall, however, these racial and ethnic disparities 
of differences within these populations become statistically insignificant 
in this Philadelphia dataset. It is likely, then, that the poor (not a 
particular racial/ethnic group) are disproportionately burdened by food 
insecurity.   

On the other hand, between those who were at risk for food 
insecurity and those who were not at risk, the differences in health 
conditions did not disappear when restricted to the low-income 
population. In Table 2 (previous page), we show that among those who 
had cut a meal due to lack of money were almost two times more likely 
to report their health as fair/poor than households who had not cut a meal 
(48.2% vs. 26.1%). Adults from households with children that had cut a 
meal reported significantly higher rates of having a diagnosis of a mental 
health condition compared to those who had no reported food problems 
(22.6% vs. 15.6%). Finally, among those that had cut a meal, the rate of 
reporting on having been sick, but not seeking medical care due to cost, 
was three times higher than those households that did not cut a meal 
(35.1% vs. 9.9%). Each of these differences in health conditions was 
statistically significant. As this population-based Philadelphia data show, 
risk of food deprivation is an important risk factor to consider when 
measuring lack of access to care and poor health outcomes. 

 
Making the Case for Children: 

Food Insecurity, Child Health and Development 

Everything from cognitive development, fine and gross motor skill 
development, to educational attainment and psychosocial disorders are 
linked to a child’s nutritional status. Overall, scientific research 
demonstrates that the lack of an adequate, nutritious diet can have long 
lasting effects upon a child’s developing mind and body (Rose-Jacobs et 
al. 2008; Cook and Frank 2008; Walker et al. 2007). 

The Philadelphia GROW Project participates in the national multi-
site study entitled the Children’s Sentinel Nutrition Assessment Program 
(C-SNAP). As a multi-site study of families who have children under the 
age of three, the C-SNAP study demonstrates that children who lived in 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         63 
 
 
 

 

households that are identified as food insecure were two times more 
likely to have reported fair/poor health, and were 30% more likely to be 
hospitalized than children who were in food secure households (Cook et 
al. 2004). Children who are food insecure are more likely to have 
delayed cognitive abilities, behavioral issues, psychosocial dysfunction, 
and continuing poor health as they mature into adulthood (Cook et al. 
2006).   

Compared to children in food secure homes, school-age children in 
food insecure homes were more likely to have seen a psychologist, have 
lower grades, and were reported to have greater difficulty interacting 
with their peers (Alaimo et al. 2001). A more recent study has shown that 
even the mildest forms of food insecurity are associated with poor 
performance on standardized tests in reading and mathematics (Jyoti et 
al. 2005). 

Food insecurity is thus an important factor in a child’s performance 
in school, and later, a significant factor in their earning potential. For this 
reason, it is important to intervene in a child’s life early on, before they 
reach school age. The national C-SNAP study has found that infants and 
toddlers who lived in households that reported food insecurity had a 1.73 
times greater odds of developmental risk than infants and toddlers in 
households that were food secure. These findings remain consistent even 
after controlling for other factors such as mother’s educational 
attainment, child’s medical history, and child’s birth weight. 
Developmental risk is an indicator of delayed emotional cognitive, 
physical, and social abilities necessary for a child’s full developmental 
potential (Rose-Jacobs et al. 2008). 

Researchers in education and economics have demonstrated that by 
the time a child reaches kindergarten, if they are behind in reading 
readiness, it is already almost too late for the child to catch up with their 
peers (Heckman 2007, 2004). In Philadelphia the educational attainment 
of the children should be of serious concern, as one in three children is 
already behind in reading preparedness by the time they reach 
kindergarten (Blue Ribbon Commission 2007). While there are many 
social and emotional factors associated with readiness for school, one 
particular factor – household food insecurity – is preventable. 

Research on the welfare support systems demonstrates that the Food 
Stamp Program, the Women, Infants, and Children’s Supplemental 



64 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

Nutrition Program (WIC), housing subsidies, and heating assistance can 
have a positive impact on protecting children from nutritional 
deprivation and from poor health.   

The C-SNAP study has also shown that children who were in 
families that received WIC benefits compared to eligible families who 
did not receive WIC had better reported health, and were also less likely 
to be underweight (Black et al. 2004). When a child is underweight 
compared to other children their age, the risk for poor health and 
development are far greater (Walker et al. 2007; Chilton et al. 2007).  
Similar results are found for food stamp receipt. The C-SNAP study 
found that families who were cut off (sanctioned) from food stamp 
benefits in the previous year of being interviewed were more likely to be 
food insecure and to experience higher rates of fair/poor health compared 
to families whose food stamp receipt was stable [Neault et al. 2004; 
Frank and C-SNAP Study Group 2006; Children's Sentinel Nutrition 
Assessment Program (C-SNAP) 2007].   

Other income support programs, over and above the food assistance 
programs, can also assist in protecting a child’s health and food 
insecurity status. Families that received housing subsidies, compared to 
children in households that were on a waiting list or had not received 
subsidies but were eligible, showed overall healthier weights for age 
(Meyers et al. 2005). Such research shows that food insecurity is 
intricately related to housing stability and child wellbeing (Kushel et al. 
2006). Similarly, families that received energy assistance in the form of 
the Low Income Heat and Energy Assistance Program (LIHEAP) 
demonstrated better nutritional wellbeing than children in eligible 
households that did not receive LIHEAP assistance. Those that did not 
receive LIHEAP but were eligible had higher odds of being hospitalized 
compared to children whose households received LIHEAP assistance.  
This interplay between LIHEAP and child health as it relates to food 
insecurity demonstrates that families often must trade off paying for food 
or paying for heat, and that intermittent exposure to unheated or half-
heated homes can be associated with illness to the point of 
hospitalization (Frank et al. 1996; Frank et al. 2006). In addition, if a 
child does not have proper nutritional intake, their bodies are less capable 
of fighting off infection (Bhaskaram 2002). 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         65 
 
 
 

 

Overall, this research provides compelling evidence that federal, 
state, and city programs and policies can have a strong impact on the 
health and wellbeing of young children.   

 

Making the Case for Mothers: 
Food Insecurity and Maternal Depression 

 
The relationship between food insecurity and mental health has also 

received a great deal of attention in the past decade. A groundbreaking 
study by Alaimo demonstrated that, after controlling for income, 
education, and health status, household food insecurity was related to 
increased risk for dysthemia and suicidal ideation among adolescents 
(Alaimo et al. 2002). The relationship is similar among mothers of young 
children. 

Food insecure women have described experiences of alienation and 
anxiety, coupled with worries about losing their children and family 
strife (Hamelin et al. 2002; Hamelin et al. 1999). In a nationally 
representative sample in Canada, individuals from food insecure 
households reported higher odds of depression and stress (Vozoris and 
Tarasuk 2003). Among homeless or poorly-housed women in 
Massachusetts, food insecurity was associated with higher rates of post-
traumatic stress disorder due to adverse childhood experiences (Weinreb 
et al. 2002). Among African-American women who chronically utilize 
food pantries in Philadelphia, anxiety, violence and stress were strongly 
associated with the experience of hunger (Chilton and Booth 2007). 

Other C-SNAP studies demonstrate household food insecurity is 
associated with a 260% increased risk for maternal depressive symptoms 
(Casey et al. 2004; Zaslow et al. 2008; Bronte-Tinkew et al. 2007).  
Maternal depression is central to the health and wellbeing of young 
children, as it is associated with greater probability of poor development, 
and behavioral and emotional problems in children (Williams and 
Carmichael 1991; Beardslee 1989; Zuckerman and Beardslee 1987; 
Downey and Coyne 1990; Petterson and Albers 2001). These 
associations of poor child development, poor child health and 
problematic behavior are generally due to disordered parent-child 
interactions, ineffective parenting, or to marital distress (Reis 1988; 



66 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

Leadbeater and Bishop 1996; Hall and Farel 1988; Chavkin and Wise 
2002; Romero et al. 2002). 

Policy interventions related to access to health insurance coverage 
have shown substantial effectiveness in reducing risk for prolonged 
maternal depression (Kahn et al. 1999; Murray et al. 2003; Bramesfeld et 
al. 2006; Melfi et al. 1999; Melfi et al. 2000). But policy interventions 
related to maternal depression and food insecurity interplay are not 
limited to health care access, and sustained access behavioral health care 
treatment, but also to such food programs as the WIC program. The C-
SNAP study has demonstrated that not only does the WIC program show 
an association with healthier weights and reported health in very young 
children, but it is also associated with a decreased risk of maternal 
depressive symptoms (Casey et al. 2004).  

Overall, while the effects of food insecurity can be devastating to the 
health and development of young children, and to the depression of their 
mothers, there are policy interventions that could mitigate the effects.  To 
begin with, however, it is important to consider the magnitude of the 
associations between household food insecurity and poor health at our 
local level. 

  

Food Insecurity in Philadelphia — Results from the 
Philadelphia GROW Project 

The Philadelphia GROW Project participates in the multi-site 
Children’s Sentinel Nutrition Assessment Program (C-SNAP) study, 
carrying out research in the emergency department of St. Christopher’s 
Hospital for Children. In Philadelphia, our GROW Project results show 
that, over the course two and a half years of data collection (February 
2005 - June 2007), 13% of young children requiring emergency care live 
in food insecure homes. 

Methodology 

The Children’s Sentinel Nutrition Assessment Program – 
Philadelphia (C-SNAP) conducts emergency room interviews at St. 
Christopher’s Hospital for Children in Northeast Philadelphia. Four to 
six days per week, interviewers approach families with children who are 
less than 36 months old. Infants that are critically ill or injured are 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         67 
 
 
 

 

excluded from approaches. In order to qualify for the interview, the 
caregiver must have knowledge about the child’s household and have not 
participated in a C-SNAP interview in the previous six months.  
Interviews are carried out in both English and Spanish. Institutional 
Review Board approval was granted by Drexel University and St. 
Christopher’s Hospital for Children. 

For this study, the sample included families without private health 
insurance. Of the 2,061 interviewed over 14 months, 246 (11.9%) 
received private insurance or had an unknown insurance status. Our 
restriction to those without private insurance serves as a proxy for low 
income, as those on Medicaid or public insurance qualify with certain 
low-income criteria, and those without insurance are generally low-
income, underemployed or ineligible for reasons such as immigration 
status. There were 115 (5.6%) participants who were not born in the 
United States. These were excluded from the analysis because of the 
variability and uncertainty of their eligibility for public assistance 
programs. Between January 2005 and June 2007, 1,694 families with 
young children fit the criteria for this study. 

The C-SNAP interview survey includes a variety of measures of 
demographic information such as race/ethnicity, educational status, 
employment and household participation in public assistance programs. 
It also asks questions about children’s health, household food security, 
maternal depressive symptoms, and parental assessment of their child’s 
development. The U.S. Food Security Scale is a reliable, valid, 18-item 
scale score that measures household food security over the previous year 
(Bickel et al. 2000). Households are defined as food insecure if they 
answer more than three responses to the 18 questions in the affirmative, 
acknowledging the lack of available, nutritious foods or if they could not 
afford food (Nord et al. 2006). The Parents’ Evaluations of 
Developmental Status (PEDS) is a screening instrument approved by the 
American Academy of Pediatrics and validated for children aged four 
months to seven years to determine an array of developmental areas 
(Glascoe 2000; Brothers et al. 2008). Eight developmental areas are 
assessed including language, fine and gross motor skills, behavior, self-
help, school, and social/emotional development using the following 
responses: yes, no, or a little. Scores are determined based upon the age 
of the child. Respondent depressive scores (most often mothers) were 
calculated after asking three questions using an instrument that has 100% 



68 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

sensitivity, 88% specificity, and 66% predictive value (Kemper and 
Babonis 1992). If the respondent answered “yes” to two of the three 
questions, the depression score was marked as positive.  At the end of the 
interview, the child’s weight and length are recorded and verified using 
the computer system in the emergency room at St. Christopher’s Hospital 
for Children. 

Data Analysis 

For univariate analysis of categorical variables we utilized chi-square 
tests; for numeric variables we used unpaired t-tests and Mann-Whitney 
U tests. The statistical level employed for each was p < 0.05 to determine 
associations between variables. To assess the association between 
household food insecurity and poor child health, developmental risk, and 
maternal depressive symptoms, we conducted logistic regressions using 
SPSS version 15. Confidence intervals were set at 95%. Based on results 
of the univariate chi-square analyses, and based on evidence in the 
literature, the following variables were controlled in the logistic 
regression analyses: maternal age, race/ethnicity, breastfeeding, and 
infant birth weight. 

Results 

In the sample of 1,694 infants and their parents, 13% (N=268) 
reported household food insecurity (see Table 3, following page). 
Prevalence of household food insecurity among the top three race/ethnic 
groups in the sample (white, black, and Latino) did not differ statistically 
(p = .6510). Although the sample does not indicate a significant 
difference in food insecurity between race/ethnic groups, it is important 
to highlight that among the general population (without consideration of 
income), differences in food insecurity between racial/ethnic groups exist 
in Philadelphia, as seen previously in Table 2 (page 61).  



Mariana Chilton, Michelle Chyatte, and Edward Gracely         69 
 
 
 

 

Table 3.  Characteristics of Household Food Insecurity 
Identified at St. Christopher’s Hospital for Children 

C-SNAP-Philadelphia Sample January 2005 - June 2007.  N=1,694 

 
Variable 

Food Secure 
Households 

N=1,426 
69.2% 

Food Insecure 
Households 

N=268 
13.0% 

P Value 

Mother’s Age in Years: Mean (SD) 24.71 (6.114) 25.45 (6.518) .0360+^ 

Mother Marital Status: 
    Married 
    Single 

 
14.5% 
85.5% 

 
 11.2% 
 88.8% 

.1570 

Race/ethnicity:* 
    Black 
    Latino 
    White 

 
36.2% 
52.0% 
11.8% 

 
33.5% 
55.0% 
11.5% 

 
 

.6510 

Maternal Education 
     Incomplete High School 
     Complete High School/GED 
     College Graduates 

 
33.3% 
38.8% 
22.9% 

 
44.++6% 

34.8% 
20.6% 

 
 

.1610 

Child Health Insurance: 
     Public 
     None 

 
97.8% 
2.2% 

 
98.5% 
1.5% 

.4700 

Mean Child Age Months (SD) 14.3 (9.81) 14.3 (9.37) .9600++ 

Low Birth Weight (<2500 grams) 13.1% 12.5% .7930 

Child Breastfed 34.5% 41.8%   .0220^ 

Household Participation in Public 
Assistance: 
    TANF 
    Food Stamps 
    WIC 
    Subsidized Housing 
    Subsidized Child Care 

 
 

42.1% 
58.5% 
81.2% 
 11.4%  
17.8% 

 
 

56.0% 
68.5% 
86.6% 

         14.5% 
         17.9% 

 
 

<.0010^ 
<.0020^ 
  .0370^ 

    .1750 
    .9700 

Note: All tests were Chi-Square Test unless otherwise indicated. 

+ Mann Whitney U test, ++ Unpaired t-test. 

* The Race/Ethnicity category only includes the top three races/ethnicities within the C-
SNAP Philadelphia sample and does not include mixed-Hispanic or Asian populations 
due to the small sampling of those populations. 

^ Statistical tests indicate a significant relationship between the variable and food 
insecurity among the C-SNAP-Philadelphia sample. 

 



70 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

There was not a statistically significant difference in marital status 
between the food secure and the food insecure mothers. There also were 
no significant differences between the groups on health insurance status 
(public insurance or no insurance), or child’s birthweight. Those families 
that were food insecure were more likely to breastfeed, compared to the 
food secure households: 41.8% and 34.5% respectively, p = .0220. 
Overall, households that reported food insecurity reported higher rates of 
participation in TANF, food stamps, and WIC, as expected. There were 
no differences overall in the utilization of subsidized housing and child 
care. 

 

Table 4.  Multiple Logistic Regression on Household Food 
Insecurity, Reported Child Health, and Maternal Depressive 

Symptoms 

C-SNAP-Philadelphia Sample: January 2005 - June 2007 

Outcome 
Adjusted Odds  

Ratio 
95%  Confidence 

Interval 
P Value 

Multiple Logistic Regression* 

Reported Child Health 
Fair/Poor 

   

Household Food Secure 1.00 referent referent 

Household Food Insecure 1.49 (1.04, 2.11) .028^ 
Developmental Risk 
(PEDS)** 

 

Household Food Secure 1.00 referent referent 

Household Food Insecure 1.83 (1.31, 2.55) .000^ 
Maternal Depressive 
Symptoms  

   

Household Food Security 1.00 referent referent 

Household Food Insecure 3.07 (2.31, 4.09) .000^ 
 * All multiple logistic regression analyses controlled for birth weight, race, 

breastfeeding, and maternal age to predict child health, developmental risk, or 
maternal depressive symptoms. 

 **PEDS is the Parents’ Evaluation of Developmental Status.  

 ^ Indicates significance p < .05. 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         71 
 
 
 

 

Results of the multiple logistic regressions shown in Table 4 (page 
70) reveal that food insecurity is significantly associated with a child’s 
reported health status, parental report of developmental risk, and reported 
maternal depressive scores after controlling for race/ethnicity, maternal 
age, breastfeeding, and birthweight. Among the households that were 
food insecure, parents were 1.49 times more likely to report their child in 
fair or poor health than those parents living in food secure households (p 
= .0280).  In other words, for children in food insecure households, there 
was a 49% greater risk of being reported to be in fair or poor health.  
Young children who were in households that reported food insecurity 
were 1.83 times more likely to be at risk for developmental delay than 
children in food secure homes (adjusted odds ratio 1.83, p < .0001).  
Finally, mothers who lived in food insecure households were three times 
more likely to report maternal depressive symptoms than mothers who 
lived in food secure households (p < .0001).   

 

Discussion 

Local data on infants and toddlers and their mothers in Philadelphia 
demonstrate that the overall percentage of household food insecurity 
among households that utilize the emergency department of St. 
Christopher’s Hospital for Children is at 13%, that food insecurity is 
strongly associated with an increased rate of fair/poor child health, 
developmental risk, and maternal depressive symptoms. What is 
happening in Philadelphia is similar to the national trends in food 
insecurity and poor child health, developmental risk and depression.  
Maternal depression also compounds the negative effects that food 
insecurity and poverty already have on children (Petterson and Albers 
2001).  These associations remain consistent after controlling for several 
variables known in the food insecurity literature as having potential 
confounding effects such as birthweight, maternal education level, and 
insurance status. 

There are several plausible explanations for these associations. Food 
insecure infants and toddlers primarily live in poverty where their parents 
may struggle to not only provide housing, health care, and child care, but 
also adequate nutrition for their children. Lack of access to adequate, 
quality food in Philadelphia’s poor neighborhoods may also exacerbate 
poor health outcomes for these infants (Chilton 2004; Chilton et al. 2004; 



72 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

Chilton and DaCosta 2008). Moreover, poor nutrition caused by food 
insecurity can limit a child’s ability to fight off infections, and maintain 
overall good health (Cook et al. 2004; Cook et al. 2006; Casey et al. 
2001; Skalicky et al. 2006). Maternal depression may be related to 
inability to work and sustain gainful employment at a living wage, which 
in turn could negatively affect a woman’s potential to purchase enough 
healthy food for her household (Zaslow et al. 2008).   

Childhood hunger is a preventable condition. Our results suggest that 
it is damaging the developmental trajectories of Philadelphia’s youngest 
children, and truncating the potential of their parents. 

Legislators and policymakers can have a profound impact if they 
intervene early in a child’s life. Nobel Laureate James Heckman and his 
team have shown that the best investments in human potential are those 
made in the earliest years of life. The highest return on investment early 
in life is found in greater academic achievement, improved health and 
reduced cost to the health system, and better earning potential (Heckman 
2006). Investment through social programs at early ages literally 
“multiplies” skills (Heckman 2007). 

There are interventions that help mitigate the effects of food 
insecurity such as: The Federal Food Stamp Program, Medicaid, the 
Supplemental Nutrition Program for Women, Infants, and Children 
(WIC), and Head Start Programs. For example, food stamps helped 
reduce the child poverty gap by almost 20% in 2004 (United States 
Department of Agriculture 2005). Children who receive food stamps 
were 26% less likely to be food insecure than those children who are 
eligible but did not receive food stamps (Lee et al. 2006). Children 
enrolled in Medicaid who also utilized food stamps from birth have 
lower health care costs associated with anemia and severe undernutrition 
(Lee et al. 2006). Families who received food stamp assistance between 
kindergarten and first grade demonstrated better examination results on 
standardized math tests compared to families who stopped receiving food 
stamp benefits (Frongillo et al. 2006).   

Food assistance and income support programs are sound 
investments. For every dollar spent on food stamps, almost two dollars 
are spent in the local economy. The beneficial effects of WIC have been 
shown to save direct and indirect medical costs from $1.71 to $3.00 for 
every dollar spent on WIC (Devaney and Schirm 1993). Enrollment in 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         73 
 
 
 

 

these programs can improve infant health outcomes and can begin to 
break the cycle of poverty. These programs provide families assistance 
with access to food and intervention programs that can help facilitate 
infant development.   

While food stamps provide essential support to families – especially 
young children – they still cannot provide enough protection against food 
insecurity and poor nutrition. Our most recent “Real Cost of the Healthy 
Diet research” where we surveyed 16 stores in the Philadelphia area 
according to the Thrifty Food Plan (TFP) food lists, reveals that even if a 
family was receiving the maximum allotment of food stamp dollars 
based on the supposed cost of the “thrifty food plan” families would be 
short on average $192 dollars per month, or $2,300 dollars per year. That 
is, what the TFP of the food stamp program supposes is $1 worth of 
food, is actually 74 cents worth of food. With the rising cost of food and 
fuel, this will likely get worse (Chilton and Cook 2008). Despite, and 
perhaps in consideration of some of the weaknesses of the safety net 
programs, there are several things that state legislators and policymakers 
can do to intervene for low-income families at nutritional risk.  

 

Recommendations for Legislative and 
Administrative Intervention 

Policy change to improve the heath of infants and toddlers requires 
focus on issues of food insecurity, as well as economic security and 
access to health care. Each of these recommendations can have 
immediate and long-term impacts on the health and wellbeing of 
children, as young children are in the most important and critical stage of 
development where a boost in nutrition access, or in mental health care 
access can have a magnified impact on a child’s present and future and 
health. 

Economic Support Programs 

 The Pennsylvania Department of Labor and Industry should continue 
to work to continue to increase the minimum wage. This would 
increase buying power, and increase access to nutritious food for the 
whole family. This is urgent especially because of the steep rise in 
the costs of fuel and food. 



74 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

Nutrition Programs 

 Ensure every last food stamp dollar is utilized. The Department of 
Welfare could step up efforts to increase enrollment in food stamps 
by providing more venues through which to determine eligibility.  
Food stamp outreach could be performed at city health centers and 
hospitals, and in locations that reach citizen children of immigrants 
and other eligible immigrant families. 

 Bolster the amount of food stamps families can receive by increasing 
access to the Low Income Home Energy Assistance (LIHEAP). If a 
family is deemed eligible for LIHEAP, the calculation for their food 
stamp allotment will increase. New York and Massachusetts are 
doing this already. Pennsylvania could follow suit. 

 The appropriate state agencies should ensure that food stamp and 
WIC offices have extended operating hours to accommodate 
working families. 

 Consider supplementing the food stamp dollar. For instance, New 
York City is implementing “health bucks,” where for every $5 spent 
on produce, the food stamp recipient receives an extra food stamp 
dollar from the city. This enhances money spent on healthier foods, 
and increases purchasing power.  

 Ensure that all eligible day care centers are receiving the federal 
entitlement benefits of the Child and Adult Care Food Program 
(CACFP). This can be done by increasing outreach to child care 
agencies and ensuring they have the tools necessary to apply for 
CACFP benefits. 

Access to Income Support Programs 

 The Department of Welfare should enhance outreach and marketing 
of the COMPASS system (Commonwealth of Pennsylvania Access 
to Social Services) to make it widely available and known to all 
social service and health care agencies within the state.   

 The Department of Welfare should consider categorical eligibility 
for a variety of programs – that is: if a family is eligible for TANF 
and food stamps, they should automatically be considered eligible 
for other programs administered by DPW. The burden of 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         75 
 
 
 

 

administrative paperwork, and need for documentation should also 
be minimized, especially since DPW already has access to multiple 
databases that contain income and other essential financial 
information. 

 The Department of Welfare and the governor should ensure that all 
LIHEAP dollars get to the families with young children who need 
these federal subsidies the most for the full extent of the cold season, 
and should consider keeping LIHEAP open all year round as do 
other states.  

Health Care Settings and Early Intervention 

 The state and city health departments can remove barriers to mental 
health care for mothers of young children by integrating behavioral 
and mental health programs into primary care settings.   

 The Department of Welfare and city health departments should 
collaborate more effectively to reduce wait times between positive 
screen for depression and access to the first appointment with a 
mental health care provider. 

 Ensure that early intervention programs, such as ChildLink and 
Elwyn, have the training necessary to ask about and respond to needs 
related to food insecurity and parents’ participation in the food stamp 
and WIC programs. 

 Encourage all Medicaid-participating pediatricians to ask if a parent 
needs help with buying food, and ensure proper food stamp and WIC 
outreach. 

Incorporate Statewide Data Tracking System for Food Insecurity 
and Undernutrition 

 The Department of Health should expand their mandate for growth 
screening and data management tracking for school age children to 
all children to include children in child care and pre-school. 

 The Department of Health should collaborate with other agencies to 
integrate the USDA Food Security Short Form (Blumberg et al. 
1999) into an annual state tracking system on the health and 
wellbeing of young children. 



76 EVIDENCE THAT YOUNG CHILDREN ARE FALLING THROUGH THE SAFETY 
NET:  POLICY IMPLICATIONS OF HUNGER AND POOR HEALTH IN PA 

 
 

 

 Consider expanding the state supported Kindergarten Initiative, 
which seeks to teach kindergarteners about farms and healthy food, 
to younger children in preschools and day care centers. 

Coordinate Efforts Across State Agencies 

 The Governor’s Inter-Agency Council on Food and Nutrition was 
created to address poor nutrition and related conditions of poverty.  
The Council consists of representatives from six executive agencies: 
Aging, Agriculture, Community and Economic Development, 
Education, Health, and Public Welfare. This council currently has no 
funded staff to administrate the work of this Council, nor report on 
the implementation of recommendations found in the Governor’s 
Blue Print to End Hunger, 2007. We recommend ensuring that there 
is a fully funded, full-time staff person and sufficient funding 1) to 
allow this group to carry out its mandate; and 2) for the public to 
participate in the development of related programs so that they can 
hold Pennsylvania legislators accountable for improving the health 
and nutritional wellbeing of young children. 

 

Conclusion 

This study shows that food insecurity and infant development is a 
concern not just for those in public health or medicine, but also for 
policymakers that can improve the immediate health and well-being of 
the youngest residents in Pennsylvania. Our research shows that food 
insecurity is also significantly associated with a child’s health status, 
child development, and maternal depression.  Public health, medical, and 
economic research have made tremendous strides within the past decades 
to understand the complex nature of poverty, poor nutrition and health 
status. There is no one easy solution to breaking the cycle of poverty and 
poor child health, but there are known interventions that can mitigate and 
prevent household food insecurity. Food stamps and other nutrition 
programs such as WIC, CACFP, LIHEAP, housing assistance and cash 
assistance act together as a health buffer for small, developing children.  
Nutrition programs and income support programs are an excellent federal 
and state investment. They not only help to close the poverty and 
education gap, but they also facilitate the physical, cognitive, social, and 
cognitive development of children.  Investing in young children now will 



Mariana Chilton, Michelle Chyatte, and Edward Gracely         77 
 
 
 

 

make the Commonwealth a state that can enjoy the benefits of having 
helped young children who are alive and developing before our very 
eyes, and the benefits of having promoted their full potential and 
capabilities. 

 

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