The Impact of Social Injustice on Nutrition

Barry S. Levy, MD, PHH, is an Adjunct Professor of Public Health at Tufts University School of Medicine and a consultant in occupational and environmental health.  Victor W. Sidel, MD, is Distinguished University Professor of Social Medicine at Montefiore Medical Center and Albert Einstein College of Medicine, and an Adjunct Professor of Public Health at Weill Medical College of Cornell University.  Together they edited, Social Injustice and Public Health, which looks at many aspects of social injustice and their relationship to public health. Major sections of the book focus on population groups affected by social injustice, areas of public health and medical care in which social injustice has an adverse impact, and approaches to the reduction and elimination of social injustice and its adverse effects on public health. In the excerpt below, from the essay “Nutrition” by J. Larry Brown, we learn about malnutrition’s effect in the United States.

While debate about the causes and remedies of hunger is conducted in the political arena, hunger itself is a public health issue.  The adverse consequences of chronic undernutrition, as well as the social sequelae, make hunger a critical problem for the nation.  Moreover, an increasing body of knowledge points to the problem of obesity as a health consequence frequently associated with inadequate income and even hunger.

In the United States, hunger presents quite differently than it does in developing nations. Protein-calorie malnutrition, or marasmas, and kwashiorkor, characterized by adequate calories but extreme protein deficiency, now occur in the United States only rarely.  Rather, hunger in this country typically takes the form of what the World Health Organization called “silent undernutrition.”  It is reflected in young children who are several pounds beneath the low end of the pediatric growth chart.  They may look simply like thin children, but a trained health professional will recognize that they are experiencing growth failure.  Although their symptoms are different from those of malnourished children in developing countries, they are, from a health perspective, in difficulty…

Because children grow and their height and weight gains are plotted on internationally used pediatric growth charts, they are perhaps the easiest population group in which to detect the consequences of inadequate nutrition.  Typically, youngsters who fall below the fifth percentile in weight or height for age on growth charts are candidates for further investigation.  To be certain, it is expected that normally 5 percent of any population would fall in this low end of the range; but in studies of low-income children, 10 to 15 percent do so.  This indicates that what is being observed is not normal genetic variation but rather a “human-made” outcome.  Moreover, this analysis is confirmed in the work of child development clinics in urban teaching hospitals across the United States, where children experiencing growth failure due to poverty are nursed back to health with appropriate nutrition.

While the relationship between inadequate nutritional intake and health status reflected in the height and weight of children is well established, scientific research in recent years has broadened our understanding of other insidious effects.  Direct links exist between inadequate food intake and a variety of poor developmental outcomes in children.  The health status of children from impoverished homes experiencing hunger and food insecurity is much worse that that of other children.  They get sick more often, have much higher rates of both iron-deficiency anemia and serious ear infections, and are hospitalized more frequently.

As a results, low-income children miss more days of school and are less prepared to learn when they do attend, making the relationship of food intake, health status, and learning far more poignant than previously understood.  Further exacerbating this interactive impairment of young bodies and minds are behavioral and emotional outcomes that accompany food deprivation.  Poorly nourished children have significantly higher rates of emotional problems, mental disorders, and withdrawn or disruptive behavior…

…Food deprivation is associated with considerable psychological and emotional distress in children.  In controlled studies, low-income children from households with inadequate food were more likely to exhibit impaired psychosocial functioning, including higher levels of anxiety, irritability, hyperactivity, and aggression.  In a national sample, children from food-deprived households manifested significantly higher levels of aggressive and destructive and withdrawn behavior.  Related outcomes apparently extend into the teenage years as well.  Two studies have shown that food-insufficient teenagers are more likely to have no friends and to exhibit both depressive disorders and suicidal behaviors.  Such efforts, not surprisingly, seem to be expressed in the educational environment as well.  Hungry children are much more likely to have had mental health counseling and to require special education services.

Nutritional status and cognitive function in children are strongly linked.  Children from food-insufficient households do not perform as well on academic achievement tests as do food-sufficient children.  In some studies, hungry children not only have higher rates of lateness and absence but also are more likely to have to repeat a grade in school.  For example, in two national studies of elementary school children, household food hardships were negatively correlated with school test results and achievement test results.  In another national study of kindergartners, children from food-deprived households not only entered school less prepared to learn mathematics but also learned less over the course of the year.

Food deprivation impairs cognitive function.  In a nutrient-deprived state, the body allocates energy (a) first to critical organ function, (b) then to height and weight gain, and (c) then to the role of the nervous system in one’s interaction with the environment, including listening to parents, dealing with peers, and learning.  If there is insufficient energy to enable a child to carry out the latter activities, cognitive dysfunction results.  Children from hungry and food-insecure homes are more likely to repeat grades, be absent or late, and be suspended from school.  The public health and economic implications of all this evidence are significant.

In general, low-income families know what constitutes a nutritious diet as well as the rest of the population.  Because limited income constrains their purchasing choices- for example, fresh fruits and vegetables typically are too expensive for them- their intake of required nutrients is significantly lower than both the Recommended Dietary Allowances (RDAs) and that of the general population.

Pregnancy is a period of significant risk from dietary inadequacy because a woman needs nutrient energy not only for herself but also fro the growing fetus.  Stores of maternal nutrients may be depleted, and maternal anemia can be one consequence.  The primary risk is borne by the fetus, including presmaturity (birth at less than 37 weeks’ gestation) and low birth weight (less than 2500 grams, or approximately 5.5. pounds).  Infants born too early of too small, or both, are not well equipped for extrauterine life.  Sequelae include respiratiory distress syndrome, weakening of the immune system, and long-term developmental problems.  The most paramount threat, however, is death, because low birth weight infants account for 75 percent of deaths to infants the first month of life (neonatal deaths).