Nutrition

for children with special health care needs

Volume 27, No. 3 May/June 2012

Food Insecurity and Children with Special Health Care Needs

Dorigen Keeney, MS, RD, CD
dkeeney@hungerfreevt.org Program Director, Hunger Free Vermont, South Burlington, VT Adjunct Lecturer - University of Vermont Interdisciplinary Leadership Education for Health Professionals; LEND Program Burlington, VT

Molly Holland, MPH, RD, CD

Malai.Holland@state.vt.us CSHN State Nutrition Consultant/Metabolic Clinic, Vermont Department of Helath and Research Associate, Center on Disability and Community Inclusion (CDCI) University of Vermont Burlington, VT

Special thanks to Jessica Aragona, MS, RD for her contributions to this article.

When a sandy-haired, good-natured 8-year-old named Jeremy came to see me in my clinic with abdominal pain, I bent over backward to find out why his tummy hurt. I poked and prodded; did testsand took X-rays. When those tests came back normal, I did more. I had trained at a top medical school and gone on to one of the best residencies in my specialty; in Jeremy, I thought I had identified a real clinical mystery. But in the end, the mystery was not a best-seller: It turned out that Jeremys family couldnt afford to buy food.
From Funding Healthy Society Helps Cure Health Care, Dr. Laura Gottlieb, San Francisco Chronicle, August 23, 2010

did not have a consistent supply of nutritionally adequate food due to economic constraint and therefore were considered food insecure.1 The rate of food insecurity is almost double (39%) for low income families with children. Poverty guidelines are prepared yearly by the Assistant Secretary for Planning and Evaluation (ASPE) from the US Department of Health and Human Services (HHS) (See aspe.hhs. gov/poverty/12poverty.shtml .) ASPE does not provide percent of poverty information; for example, a low income for a family of four is defined as a family income of less than 185% of poverty or a total family income of less than

INTRODUCTION
The paragraph above is powerful, illustrating how health care providers may overlook issues of food insecurity in our society. One might wonder how much the tests and procedures cost the health care system. On the individual level, this family spent time, worry, and probably money getting their son tested and did not get the help they needed. The purpose of this article is to raise awareness about this topic with providers who work with children and families (especially if the child has a chronic health need that may overshadow the issue of food insecurity), to review the effects of food security on childrens health, and to describe ways that health care professionals can identify and assist food insecure families. (See Glossary on page 12.) The authors introduce a Hunger Screening Algorithm (Figure 2 on page 3 and 4) used in the State of Vermont as a model for professionals to help them identify and assist families at risk for hunger. In 2010, based on the most recent reported data, 14.5% of households reported food insecurity as shown in Figure 1. Additionally, over 20% of US households with children

Figure 1 - Food Security Status of U.S. Households, 2010

CENTER ON HUMAN DEVELOPMENT AND DISABILITY, UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTON

$42,643/year. Various other federal, state and local organizations and agencies may publish percent of poverty tables for their own programs often using the poverty guidelines from ASPE to calculate 150% or 185%, etc. An example of a table of this type is available online. (See www.dhs.
ri.gov/Portals/0/Uploads/Documents/Public/General%20 DHS/FPL.pdf ).

Food insecurity is a measure of the household budget available for food and therefore represents a balance between cost of living and available resources. Households with higher expenses such as medical, transportation or housing costs have higher rates of food insecurity for the same income. Families raising a child with a disability are particularly at risk for food insecurity because of higher financial burdens and greater risk for being underemployed.3,4

Figure 3 What does food insecurity really mean?

Based on work by Mark Nord, Economic Research Service (ERS)

Why health care professionals working with CSHCN need to be aware of food access issues
Household food insecurity is associated with a myriad of adverse health outcomes for children including poor health, developmental delays, and mental health concerns.5 Health care and educational professionals should be aware of the food security status of a household and its impact on a childs health, response to therapy, and the childs ability to focus and learn. It is the authors belief that ethically, professionals who are working with families and identify that food insecurity as a potential concern for the family, should provide information on food resources.

FOOD INSECURITY
What is food security and how is it measured?
The concept of food security evolved from work done in the 1980s and 90s to measure the effect that limited resources have on the ability to procure food. Food insecurity is defined as limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.6 This definition includes the continuum of how income constraints adversely affect diet - from mild food insecurity that results in reduced quality, variety and desirability of diet to the more extreme severe food insecurity that can lead to disrupted eating patterns and reduced intake and possibly the experience of hunger.7 Households can become food insecure if income gets reduced or expenses increase, e.g., in the northern United States when winter heating bills rise. Food insecurity is not a static condition. In 2010 on average, food insecure households reported food insecurity for 7 months out of the year.1 Food access within households will follow a predictable pattern as resources fluctuate. Typically, as there is less money for food, caregivers will stretch the food dollars by purchasing cheaper foods of poorer quality and less variNutrition Focus Vol. 27 #3

ety. As resources get tighter, adult members and older children will reduce the amount of food that they eat so that the younger children will not go hungry. If the situation becomes more severe even the youngest children will go hungry. See Figure 3. Since 1995, the extent of food insecurity in the United States has been measured annually using the USDA Food Security Scale (FSS) within the yearly Current Population Survey (CPS) of the US Census.1 The USDA Food Security Scale is a validated 18-question survey that determines the extent and severity of food insecurity by asking questions that identify where households are on this food security continuum. Table 1, on page 5, illustrates the questions asked and method for this survey. Households were initially categorized as food secure, food insecure, or food insecure with hunger depending on the severity of the situation in the household. In 2006, the concept of hunger was stripped from the USDA measurement and instead the condition of food insecurity was divided into two categories of low food security and very low food security which conform to the previous definitions for food insecurity without and with hunger respectively.7 For purposes of simplicity, this article will use the previous terminology of food insecurity to encompass both low and very low food security. Therefore, the reader will understand that both reduced quality, variety and desirability and the more severe situation of disrupted eating patterns and reduced intake are included.

What are the causes of food insecurity?

The underlying cause of food insecurity is a lack of sufficient funds to purchase enough food for an active, healthy life by all members of the household throughout the year.1 Other factors, such as social isolation and mental health issues, such as depression, can reduce the ability of a caretaker to cope with the stresses of poverty and deepen food insecurity. Many studies have documented the correla(continued on page 5) tion between maternal depression and
2 May/June 2012

Figure 2. Hunger Screening Algorithm

Nutrition Focus Vol. 27 #3

May/June 2012

Nutrition Focus Vol. 27 #3

May/June 2012

increased food insecurity, although the causality in either direction is still unclear. Casey et al noted that mothers with depressive symptoms not only had higher rates of food insecurity, but also had greater odds of losing food stamp and welfare benefits and their children were in poorer health and were hospitalized more often.8 Families with a child with a chronic illness or disability have been shown to suffer increased poverty and food insecurity.9,10 These families often have higher costs for medical care, personal care, transportation or even special diets.3,4 At the same time, family income may be reduced because one parent/caregiver may be unable to have full employment and/or lose pay due to unpaid days taken off for illness or medical appointments.11 If a family has multiple risk factors (see Table 2) then the chances are even higher

that the family is suffering from food insecurity. Families often do not verbalize these issues to providers, but astute providers will recognize the risk factors and ask directed questions to the family so the necessary supports can be accessed.

Table 2 - Risk Factors for Food Insecure Households

Poverty 1, 12 Single parent household 1 Depression or other mental illness in the caregiver 12 Social isolation 13 Child with special health care needs 9, 10

Table 1 - Questions asked in the Household Food Security Scale (HFSS) questionnaire to assess the presence of hunger in families with Child Food Security Scale (CSFS) questions included (#11-18)
NOTE: For questions 1, 2, 3, and 11, 12, 13 (if applicable) the statement is read to the respondent and the respondent is asked, Was that often, some times, or never true for you in the last 12 months?
Questions 1-10 are asked to determine family food security:

1. 2. 3. 4. 5. 6. 7. 8. 9.

10.

We worried whether our food would run out before we got money to buy more. The food that we bought just didnt last and we didnt have money to get more. We couldnt afford to eat balanced meals. In the last 12 months, did you or other adults in the household ever cut the size of your meal or skip meals because there wasnt enough money for food? (Yes/No) (If yes to Question 4) How often did this happen? (Almost every month/Some months but not every month/ Only 1 or 2 months) In the last 12 months, did you ever eat less than you felt you should because there wasnt enough money for food? (Yes/No) In the last 12 months, were you ever hungry, but didnt eat, because you couldnt afford enough food? (Yes/No) In the last 12 months, did you lose weight because you didnt have enough money for food? (Yes/No) In the last 12 months, did you or other adults in your household ever not eat for a whole day because there wasnt enough money for food? (Yes/No) (If yes to Question 9) How often did this happen? (Almost every month/Some months but not every month/Only 1 or 2 months)

Questions 11 - 18 are asked only if the household included children ages 0 -18 years of age

11. 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. 12. We couldnt feed our children a balanced meal, because we couldnt afford that. 13. The children were not eating enough because we just couldnt afford enough food. 14. In the last 12 months, did you ever cut the size of any of the childrens meals because there wasnt enough money for food? (Yes/No) 15. In the last 12 months, were the children ever hungry but you just couldnt afford more food? (Yes/No) 16. In the last 12 months, did any of the children ever skip a meal because there wasnt enough money for food? (Yes/No) 17. (If yes to Question 16) How often did this happen? (Almost every month/Some months but not every month/ Only 1 or 2 months?) 18. In the last 12 months, did any of the children ever not eat for a whole day because there wasnt enough money for food? (Yes/No)
For more information about this tool see http://www.fns.usda.gov/fsec/files/fsguide.pdf

Nutrition Focus Vol. 27 #3

May/June 2012

EFFECTS OF FOOD INSECURITY ON CHILDREN

Food insecurity has profound effects on the health, cognitive, and behavioral aspects of children, including adverse health effects (e.g., poor growth, obesity, iron deficiency anemia, and bone health) and feeding interactions. Food insecurity influences health and development through its effects on nutrition and as a component of overall family stress.12 Even marginal food insecurity (whereby the household has only reported one or two indicators of food disruption and therefore does not reach the threshold for being categorized as food insecure) has been found to have measurable detrimental effects on children.14 The next several sections will further describe these effects.

that boys, age 8-11 years, whose households answered positively to the child-specific items of the food insecurity screen were significantly less likely to have the recommended servings of dairy foods and calcium intake.23 These boys were also more likely to have a significantly lower estimated total body bone mineral content compared with similar food secure children. There were no calcium-related dietary factors or bone mineral content differences seen between food insecurity and girls within the study.23

Development, behavior and learning

Adverse Health Outcomes

Young children (birth to age 3) living in food insecure households were almost twice as likely to be in poor health and 31% more likely to be hospitalized compared to similar children living in food secure households.15 This study also showed that as the severity of food insecurity increased, so did the risk for the child to be in poor health indicating a dose-response. Data from NHANES showed an association between household food insecurity and symptoms of headaches and stomachaches, as well as an increased rate of colds.16 A 2002 study of 408 children in Worcester, Massachusetts, with both moderate and severe hunger found that these children have increased rates of both chronic and acute illness.17 The effects of childhood hunger can be long-lasting. A Canadian longitudinal study found that children who have ever experienced hunger, especially if they had experienced several episodes of hunger, had poorer health over the ensuing 5-10 years. Youth who had experienced several episodes of hunger had more chronic conditions including asthma and poorer health.18

Infants and toddlers in food insecure homes are more likely to be at developmental risk24 and to have increased attachment issues and decreased mental proficiency in toddlerhood as compared to similar children in food secure homes.25 Both preschool and school-age children experiencing hunger had higher rates of anxiety and depression.17 Children between 6 and 12 years of age, who were categorized as hungry, were more likely to have clinical levels of psychosocial dysfunction as measured by the Pediatric Symptom Checklist (PSC). PSC found that most all behavioral, emotional, and academic problems were more prevalent in hungry children (including use of special education, repeating a grade, conduct disorder), but aggression and anxiety had the strongest degree of association with hunger.26

Iron deficiency anemia Infants and young children are at increased risk for iron deficiency and iron deficiency anemia (IDA) due to their rapid rates of growth combined with potentially low consumption of foods rich in iron. Children in food insecure households are twice as likely to experience iron deficiency anemia as compared to children whose household was considered food secure.19 In the past few decades, research has established that IDA during the first two years of life is associated with impaired cognitive, mental and psychomotor development and that these impairments persist even after treatment of the IDA.20, 21, 22 Bone Health Calcium intake and bone health is of special nutritional concern for children in food insecure households. A 2011 study analyzing data from the 2001-2004 NHANES found
Nutrition Focus Vol. 27 #3 6

Food security impacts a childs ability to learn Using a food security measurement tool that predated (and was incorporated into) the FSS, teachers reported statistically significantly higher levels of hyperactivity, absenteeism, and tardiness among hungry/at-risk children.27 Although this study did not evaluate the reason for the changes in tardiness and absenteeism, it suggests that the availability of school breakfast encourages students to come to school, arrive on time, and further may prevent illness thus reducing absenteeism. If a child attends school less often they have fewer opportunities to learn. If they are in the classroom but are experiencing behaviors that distract them from paying attention, such as anxiety, depression or distractibility, then they also will not be able to learn to their potential. For example, children aged 616 years in food insufficient families had lower arithmetic scores, and were more likely to have repeated a grade, to have seen a psychologist, and to have had more difficulty getting along with other children, than similar children whose families were food sufficient. Teens from food insufficient households were more than twice as likely to have seen a psychologist, almost three times as likely to have been suspended, almost twice as likely to have a lot or some difficulty getting along with others, and four times as likely to have no friends. 5 Children aged 1516 years from food insufficient households were more likely to have had thoughts of death and to have attempted suicide than those in food secure households of similar income.28
May/June 2012

Food insecurity in kindergarten has been associated with lower mathematics scores, increased BMI and weight gain, and lower social skills in girls at third grade.14 Even marginal food insecurity (answering 1 or 2 of the food security questions) resulted in kindergarten children scoring lower on tests and learning less during the school year.29

in their behavior, especially increases in anxiety, aggression, depression, and hyperactive behaviors. These behaviors may be due to nutrient deficiencies, effects of periodically missing meals, or to the stress in the household. In children with special health needs, distinguishing the source of the behavior change can be difficult, but poor nutrition, missed meals or stress of household food scarcity should be considered.
Hunger Scenario: One author saw this teenager as part of a

Feeding interactions are affected

Food insecurity was associated with feeding practices that have potential to increase obesity such as feeding high calorie supplements and appetite stimulants.The authors surmised that mothers may perceive these strategies as protective against under nutrition in their children and may believe that ensuring a childs good appetite may buffer them during periods of limited food access. 30 A longitudinal study of 8,693 children at ages 9 and 24 months found that food insecurity increased obesity/overweight through poorer infant feeding practices (decreased duration of breastfeeding and early introduction of solid foods) and compromised parenting practices measured at 9 months using the Nursing Child Assessment Teaching Scale (NCATS) that rates caregiver and child interactions.31

Obesity

The relationship between obesity and food insecurity for children is complex and not entirely clear. Some studies have found that children, depending on gender and age, are at increased risk for obesity and overweight. However, other studies have not found the same association. There may be no clear association but it is compelling that within an individual household, the situation of food scarcity and overweight/obesity are both present.30 A recent study in New York City clinics found that food insecure women who were not participating in food assistance programs were at higher risk for obesity than similar women who were participating, showing the protective effect of assistance programs.33 Nutrition assistance programs that provide meals to children in school and child care, and improve access to food in the home (via SNAP and WIC), protect household members from becoming overweight through improving the quality of the diet. A clear association has been shown between a higher cost of food and a reduction in caloric density.34 Any assistance that allows the family to spend more money on food, up to a certain threshold, will result in a more nutritious and less calorie-dense diet. In summary, food insecurity at the level of the household (even when the childs nutritional status is relatively protected) has profound effects on the health, cognitive, and behavioral potential of infants, children and youth. The threshold for adverse effects of food insecurity on health and development in young children occur before the appearance of readily identifiable clinical markers, such as underweight.12 The most immediate and common change seen in children living in food insecure homes is a change
Nutrition Focus Vol. 27 #3 7

feeding team evaluation. He was referred by the high school educational team due to his oral motor feeding problems. The team asked for more advice on how to address problems with food refusal, excessive drooling and his underweight condition. As the evaluation progressed, it became evident that the young man was not eating breakfast due to time limitations and lack of hunger (like many teens) in the mornings. He did not choose to eat a school breakfast and at lunch time did not eat because he was embarrassed with his drooling and poor control over utensils. By early afternoon, his behavior began to rapidly deteriorate and he became very disruptive in his classes. Once hunger was identified as the root of the behavior problem, the school started supplying him with 8 ounces of a nutritionally complete liquid supplement mid-morning and created some adaptations for lunchtime. His behavioral problems in the classroom disappeared completely and the school personnel and his family were very pleased. This family was not experiencing food security issues, but hunger, due to other factors, became evident through his behaviors.

SCREENING FOR FOOD INSECURITY

Because food access affects so many aspects of a childs health and wellbeing, health care professionals should be aware of whether their patients are living in homes with adequate food. Families may be embarrassed to admit to not having enough food or may fear that not being able to adequately feed their child could result in accusations of neglect. Health care professionals can learn to build questions about food access into their interviews and general discussion with caretakers. For example, if a child is sick, the health care provider can ask what are the favorite comfort foods they like to give their child and then ask if there is enough money in the budget to purchase those foods. Or if a change in circumstances has been related, that is a good opener to say many families find it hard to make ends meet at the end of the month, would you like information about other food resources? It is easier to ask parents if they would like information on food resources rather than asking if they do not have enough food. Many providers make it a standard practice to provide information on WIC (Special Supplemental Nutrition Program for Women, Infants and Children), SNAP (Supplemental Nutrition Assistance Program formerly known as food stamps), or information and referral hot lines such as 2-1-1. (See Table 3 on page 9)
May/June 2012

Providers should be sensitive to clues that food access is an issue, e.g., when a caregiver is not able to follow through with dietary recommendations. The RD who is aware of the financial constraints of the family may suggest less expensive foods or foods that are available through WIC or local food pantries when making therapeutic recommendations to improve nutritional status and address sensory issues. Just as Jeremys doctor was misled about his health, many providers are also unaware of the variety of consequences that food security can have on a child. Health care providers (e.g., registered dietitians, occupational therapists, physical therapists, family educators, early interventionists) who are privileged to be working with a child in the familys home have a unique insight into the circumstances of the family. Screening for food insecurity is an important part of the job. As regular visitors, providers witness the manner in which people live and can also become aware of changes in the familys finances such as a recent job loss or additional expenses through casual conversation. All providers, whether working in home-based educational or health services (such as early intervention programs or visiting nurses program), schools (including therapists), or health care settings, who become aware that a family may be struggling to meet basic needs can be a source of information and referral to food and nutrition resources. To help guide and inform health care providers about food security, the authors have developed the Vermont Hunger Screening Algorithm (Figure 3 on pages 3 and 4). The need for this tool evolved from working with malnourished children in Vermont who had a variety of home-based educators and therapists, almost none of whom were aware of the lack of food in the house and the childs poor nutritional status. The algorithm provides a list of environmental risk factors for food insecurity and a list of signs and risks for childhood malnutrition, to alert providers to the possibility of food insecurity. The algorithm also provides information about how to talk with families about available resources and some of the food and nutrition related resources available in Vermont. This algorithm can easily be adapted for use in other locations. To download a copy of the algorithm to modify for use in other states, go to http://www.
hungerfreevt.org/images/stories/pdfs/hungerscreeningalgorithm6.pdf or contact Dorigen Keeney, dkeeney@ hungerfreevt.org , for the Publisher version of the Algo-

HOW CAN PROVIDERS ASSIST FAMILIES WITH FOOD INSECURITY?

Health care providers may become more comfortable asking about food resources if they have information to assist the family. The algorithm on pages 3 and 4 lists some of the major food assistance programs in Vermont and 2-1-1, the general information and referral toll free phone number that is available in all states. Awareness and understanding of programs, including eligibility requirements, services provided, enrollment process, and hours of service are all important for the health care provider so they can inform families of what to expect. Table 3 on page 9 provides a description of the major federal nutrition programs. In a situation where the family needs access to special assistance within a program (i.e., special formula or modified food packages for WIC), the providers contact with the program can ease the process and help make the request a success. Families with children, who participate in food assistance programs have better outcomes than those who are not getting assistance.12 Children receiving SNAP, school meals and child care meals have been shown to have better health, educational outcomes and behavior. The Box below provides an example of how full and ongoing participation can greatly assist a family.

Optimal Program Participation Example

Note Italicized items indicate program participation that reduces food insecurity in low income households

rithm to modify for your own state or region. A similar algorithm has been developed for primary care providers, which includes the two-question food security screen (see Resource 3). Table 4, on page 10, provides example screening questions to assess food security in a sensitive manner. Resources 2 and 3 provide online courses to help health care professionals learn about food insecurity.

The Adams, are a single head of household family consisting of a mother (Ann) with 2 children, Bobby, (age 6) and Mary (age 3), who live in subsidized housing in an urban area. Ann works full time as a cashier at a local department store, Bobby is in first-grade at the local elementary school where he eats school breakfast and lunch every day. He also attends an after-school program that participates in the Child and Adult Care Food Program (CACFP). Mary attends a subsidized centerbased day care that participates in the CACFP for all meals and snacks so that she receives a breakfast, lunch and snacks away from home. The family receives SNAP, and Mary is also receiving WIC benefits. In addition to these federal programs, Ann also visits the food pantry once a month and obtains the maximum amount of foods her family is eligible to receive, typically three days worth of food. Although this familys income is low, Ann does not report food insecurity since they are participating in these wage support programs.

(continued on page 10)

Nutrition Focus Vol. 27 #3

May/June 2012

Table 3. - Federal Food and Nutrition Assistance Programs *

Program Name and Purpose Type of Assistance Eligibility Requirements How this program can help

SNAP (Supplemental Nutrition Assistance Program)

www.fns.usda.gov/fsp

Purpose: improve the diets of low-income households by increasing access to food/food purchasing ability

Direct payments in the form of electronic benefits redeemable at most retail food stores

Eligibility is based on household size, income, housing costs and other factors.

CSFP (Commodity Supplemental Food Provides USDA commodity foods Program)

www.fns.usda.gov/fdd/programs/ fdpir

Purpose: improve the diets of incomeeligible participants by supplementing their diets with USDA commodity foods

It is an entitlement; Brings tax money back to local community Foods for child Frees money for other necessities Income-eligible persons, This can cover children not enrolled in WIC, over the age for WIC including pregnant and but not yet in school to breastfeeding women, receive meals with the other mothers up to 1 year school nutrition program post-partum, infants and children up to age 6, and adults older than 60. Low income individuals who obtain foods from food pantries Food

TEFAP (Temporary Emergency Food Assistance Program)

www.fns.usda.gov/fdd/programs/ tefap

Commodity foods to food pantries via food banks

Purpose: provide emergency food and nutrition assistance to low-income persons NSLP (National School Lunch and related programs) www.fns.usda.gov/cnd/lunch/ www.fns.usda.gov/cnd/breakfast/ www.fns.usda.gov/cnd/summer/ www.fns.usda.gov/cnd/afterschool/ Purpose: provide nutritious free or reduced price lunches, breakfasts, snacks or summer program meals CACFP (Child and Adult Care Food Program) www.fns.usda.gov/cnd/care/ Purpose: provide nutritious meals and snacks to participating day cares, afterschool programs and homeless shelters

Schools/programs receive cash subsidies for each meal or snack served

Public or private not-for- Provides child with nutriprofit schools, child care tionally-balanced meals institutions or summer during program hours programs for children. Financial eligibility for free or reduced price meals must be determined.

Program receives cash reimbursement for each meal or snack served

Provides child with nutritionally-balanced meals during program hours If familys current child care program does not utilize this program try to help family locate a program that provides meals Pregnant, post-partum or breastfeeding women, infants up to 1 and children up to age 5 are eligible if determined to be at nutritional risk and they meet income guidelines Provides infants and children with certain foods to supplement their diets

WIC (Special Supplemental Nutrition Program for Women, Infants and Children)
www.fns.usda.gov/wic

Purpose: provide food vouchers, nutrition information and referrals to health care for at-risk pregnant women, infants and children to age 5

Nutritious foods to supplement diets; nutrition education and counseling and screening/referrals to other health and welfare programs; fruits and vegetable in states that participate in the Farmers Market Program

* Note: Food pantries and prepared meals are also available to children and families through not-for-profit food banks and local organizations. To find out where these programs are located in your state, contact 2-1-1 or the local foodbanks.

Nutrition Focus Vol. 27 #3

May/June 2012

Table 4 - Examples of screening questions for health care professionals to use to assess food security
NOTE: We have provided various questions or examples in this table. We encourage you to identify or develop 1-2 questions or statements that may be used for screening or can be built into a general discussion with care providers to assess, in a sensitive manner, food security.

1. With the high cost of food, some of my other families say that theyve been having a tough time getting the foods they need. Would you say that is true for your family? 2. Some families have problems getting the kinds of foods that children need to be healthy. Has that been a problem for you? 3. The supplemental beverage I am suggesting (prescribing) for your child today can be expensive. Before I make any recommendations, I would like to get your permission to discuss how this might impact your family food budget. If the family provides permission to continue the discussion the health care professional might say the following: I can either make a recommendation for a commercial high calorie pediatric supplement beverage or we can talk about how to increase calories in foods/beverages using common food items you may already have at home. 4. As part of my job I offer to all families information on how to access food from government programs. Would you like information on how to access food for your family from these programs? If the family already uses a program such as WIC you can ask if they would like information on other programs besides WIC. 5. Please let me know if either of these statements is true for your family: Within the last 12 months we worried whether our food would run out before we got money to buy more. Within the past 12 months the food we bought just did not last and we did not have money to get more. 6. Which of the following statements best describes the food eaten in your household: enough of the kinds of food we want to eat enough but not always the kinds of food we want to eat sometimes not enough to eat often not enough to eat
From Laiser LL, Townsend MS. Food insecurity among US children: implications for nutrition and health. Top Clin Nutr.2005;20:313-320:

1. Do you mind if we take a look and see what you have in your kitchen so we can prepare a meal for lunch today using this new plan so you do not need to go out and buy any special foods? 2. I know we recommended a granola bar as a snack because it is crunchy and sweet and the OT is working on having Johnny take more crunchy textures. You said you dont have any on hand, but I bet we can find something else in your pantry that will be a good substitute. 3. I can go with you next time your going to the food pantry so we can pick out foods that will fit into your child s meal plan. 4. Do I have your permission to contact the day care food program manager so we can alter your childs meals to fit into this meal plan that the feeding therapist and I have developed? I also want to see if they can feed him an extra snack in the afternoon before leaving for the day.

CASE EXAMPLE
Additional information about Adrenoleukodystropy is in the box on page 11.

Harry, age 6 years, lives with his mother in a low income section of a small city. He was diagnosed with a genetic mutation of Adrenoleukodystrophy (ALD) as a toddler due to some developmental delays. He carries the gene but onset of symptoms had not yet occurred. Harry has been followed by specialists at his local hospital and at a large university hospital where he is involved in a study using Lorenzos Oil and follows a very low fat diet. Harrys diet consists of this very low fat diet, (10% of calories from fat), Lorenzos Oil, and supplementation with EFA (walnut oil).

Current and Past Hunger Program enrollment Harrys mother, Alice, is a single mother who struggles
Nutrition Focus Vol. 27 #3 10

with mental health issues (ongoing depression), and has difficulty working. They do not own a car and must rely on public transportation. The nearest large grocery store is 5 miles away so they often use the smaller corner stores located closer to their home. The family receives Section 8 housing, have fuel assistance, and participate in the SNAP program. Harry is enrolled in Medicaid which includes transportation for health care visits including yearly visits to another state to participate in the ALD study protocol. When Harry was younger he was enrolled in the WIC program. He received subsidized child care but this program did not participate in CACFP so Alice had to pack lunches and snacks for Harry. She has limited knowledge of cooking and food composition. Currently Harry receives breakfast and lunch from school and has a 504 plan so that he can receive a special meal based on his diet plan.
May/June 2012

Issues with adhering to the diet Since Harrys diet is so restrictive in fat, Alice has to purchase foods for him that are often difficult to afford or even find in the places that she would typically shop. An example is fat-free cheese that was not available at the food pantries or local corner stores. The WIC program was not allowed to provide Harry with fat free milk, so Alice purchased fat-free milk with her SNAP allocation. WIC was able to give her special vouchers for fat-free cheese, but the brand was very specific (to meet WIC regulations concerning nutrient content) and neither Harry nor his mother liked the taste and texture of this cheese. Harrys mother had strong taste preferences and did not like to serve leftovers which influenced Harrys preferences. Harry was perceived as a picky eater at his preschool program and refused many of the foods in his therapeutic diet. He tried to take foods from other children and his behavior deteriorated. When he did not like the foods served to him, his lack of intake and subsequent hunger added to his aggressive and disruptive behaviors. Dietary intake and growth information Harrys growth, despite his low fat diet and the issue of family food insecurity, was never a concern. In fact, short stature (both parents were small) and a consistent BMI at 90% became a problem during the preschool years until his personal care attendant (PCA) was able to help Harry become more physically active and obtain lower calorie food and snack choices. At his yearly visits to participate in the ALD study protocol the RD noted Harry was also deficient in vitamin E.At one point his lab work indicated he had an essential fatty acid deficiency due to the fact that he did not like the walnut oil that was prescribed. Alice also reported that sometimes she could not afford the oil and Medicaid would not pay for this food. Interventions for food assistance used by Harrys family
1. Expanded Food and Nutrition Education Program (EFNEP Cooperative Extension) - Alice received assistance with learning how to cook and prepare foods from the EFNEP home visitor. Food shopping, preparation, and menu planning basics were covered, and trips to the grocery store were included. Alices friend and neighbor, participated in many of the EFNEP sessions. She helped Alice with food preparation and provided periodic child care so Alice could go shopping alone.

3. Child Nutrition program - Once Harry started school he was able to participate in the breakfast and lunch program. The RD who worked with Harry through the metabolic program attended several 504 plan school meetings and worked with the food service staff to ensure Harrys meals met the dietary restrictions. His classroom aide was in the lunchroom with him to prevent Harry from taking other childrens food. The aide also recorded his food intake and sent this home daily.

Adrenoleukodystrophy (ALD)
There are several different types of this disease which can be inherited, but the most common form is an Xlinked condition. X-linked ALD primarily affects males, but about one in five women with the disease gene develop some symptoms. People with ALD accumulate high levels of saturated, very long chain fatty acids (VLCFA) in the brain and adrenal cortex because they do not produce the enzyme that breaks down these fatty acids in the normal manner. ALD damages the myelin sheath, a complex fatty neural tissue that insulates many nerves of the central and peripheral nervous systems. The clinical presentation is largely dependent on the age of onset of the disease. The classical, severe type is the childhood cerebral form which, as an X-linked disease, affects males. Symptoms normally start between the ages of 4 and 10 and include loss of previously acquired neurologic abilities, seizures, ataxia, Addisons disease, and degeneration of visual and auditory function. Other common symptoms are behavioral changes such as abnormal withdrawal or aggression, poor memory, and poor school performance. While there is currently no cure for the disease, some dietary treatments have been used with limited success especially before disease symptoms appear. These include a 4:1 mixture of glyceryl trioleate and glyceryl trierucate (Lorenzos oil) in combination with a diet low in VLCSFA (very long chain saturated fatty acids). The quest for a treatment for ALD was depicted in the 1992 film Lorenzos Oil. 4. Food Pantry visits - The social worker at the metabolic clinic was instrumental in advocating for Alice and Harry to receive food weekly from the pantry versus once per month. Often there were not many foods that Harry liked or were allowed on his diet, but there were foods that Alice could eat and save her money for foods she needed to purchase for Harry. One of Alices ongoing issues was that she didnt like to eat the low fat foods she prepared for Harry and she felt bad that Harry had to eat them.
11 May/June 2012

2. Federally-funded food programs - Up to age 5 years the WIC program provided Harry with vouchers for fatfree cheese. He received the standard child package and Alice purchased fat free milk using her SNAP allocation.
Nutrition Focus Vol. 27 #3

5. Farm Share from local community supported agriculture program (CSA) - The social worker also contacted the United Way program and they donated funds so that the family received a farm share from a local farm program. This allowed them to receive fresh fruits and vegetables on a weekly basis for the summer and fall growing season. 6. Personal Care Attendant (PCA) - Harry was eligible for a PCA through the state. The social worker, Harrys pediatrician, and other advocates were able to successfully obtain 15 hours of PCA hours a week for a worker to be at the home to prepare low fat meals for Harry and to help Alice with food shopping, menu planning, and other activities to insure that Harry was able to continue with successful adherence to his low fat diet. One summer the PCA was a male college student who was majoring in nutrition. He was successful in encouraging Harry to take his walnut oil or eat walnuts and worked with him with simple food preparation.

This newsletter has described the issues of food insecurity and provided information for those who work with children with special health care needs regarding this issue. Examples and case studies were provided for children with special needs. Highlights of this article to consider in your practice include: 1 in 5 children in the US live in food insecure households Children with special health care needs are at greater risk for food insecurity Food insecurity can be hidden Children in food insecure households have more behavior problems and suffer poorer health, less educational achievement and developmental delays All providers have a role in identifying food insecurity and providing families with additional food resources.

GLOSSARY
Food insufficiency: An inadequate amount of food intake due to lack of resources Hunger: A situation where household members unwillingly go without food for an intermittent period of time. Hunger is a potential consequence of food insecurity. Severe hunger: When children in the home go without food Household food insecurity: Limited or uncertain access to enough nutritious food for all household members to lead an active and healthy life due to economic constraints Safety Net programs: Programs that seek to prevent low income families from falling below a certain poverty level. They can be provided by the public sector (federal, state and local) or by the private sector (non-government programs, charities, and faith-based organizations). They exist to catch people when they fall economically and are generally intended to be temporary. The most common programs provide cash assistance, food aid and health care coverage. These programs help families by providing them with a reduced cost for goods (food via the SNAP program) or services (subsidized housing or child care) so they have money for other necessities.

Outcome Currently Harry is successfully attending first grade and his teacher and mother are both pleased with his academic success. Alice has much less stress concerning how Harry is being fed at school since the food service staff is working hard to follow his restricted fat diet. Alice indicates that since he is receiving his breakfast, lunch and snack at school, she has more money to purchase low fat foods for his dinner and weekend meals. His medical providers are pleased with his overall growth although he still is overweight. However, his overall behaviors have improved dramatically and no major symptoms of the disease have been noted. Alice admits that the diet is difficult to follow, but with the help of the PCA, the schools help with Harrys meals, and all the nutrition education she has received, she feels confident that she can manage his diet.

SUMMARY
Registered Dietitians, DTRs, and other health care professionals are in a unique position to recognize the issues associated with food insecurity in their patients, and also play a leadership role in the development of programs that can help end food insecurity. RDs and DTRs understand the effects of inadequate dietary intake and food insecurity on health and well being.35 They recognize that if a child or adult is overweight, this has nothing to do with their degree of food security. They understand that the root of classroom behavioral issues may be related to food security at home. They also recognize that children with special needs are more likely to live in food insecure homes. Reference #35 provides many suggestions for ways RDs and DTRs can contribute to the goal of improving food insecurity.
Nutrition Focus Vol. 27 #3 12

REFERENCES
1. Coleman-Jensen A, Nord M, Andrews M, Carlson S. Household Food Security in the United States in 2010. ERR-125, US Dept. of Agriculture, Econ. Res. Serv. September 2011. Online: http://www.ers.usda.gov/Publications/ERR125/ ERR125.pdf . 2. US Department of Health and Human Services. 2012 HHS Poverty Guidelines. Online: http://aspe.hhs.gov/poverty/12poverty.shtml . Accessed 07 July 2012. See Frequently Asked Questions on this page to understand how percentage multiples (150%, 185%) of poverty are determined from federal data.

May/June 2012

3. Parish SL. Material hardship in US families raising children with disabilities. Exceptional Children. 2008;75(1):71-92. 4. Lukemeyer A, Mayers MK, Smeeding T. Expensive children in poor families: out-ofpocket expenditures for the care of disabled and chronically ill children in welfare families. Journal of Marriage and the Family. 2000;62(2):399-415. 5. Alaimo C, Olson CM, Frongillo EA. Food insufficiency and American school-aged childrens cognitive, academic, and psychosocial development. Pediatrics. 2001;108:4453. 6. Bickel G, Nord M, Price C, Hamilton W, Cook J. Measuring food security in the United States: Guide to measuring household food security 3rd ed. US Department of Agriculture, 2000:1-82. Online: http://www.fns.usda.gov/fsec/files/ fsguide.pdf Accessed 03 July 2012. 7. US Department of Agriculture, Economic Research Service. Food Insecurity in the US: Definitions of food insecurity. Online: http://www.ers.usda.gov/topics/
food-nutrition-assistance/food-security-in-the-us/definitions-of-foodsecurity.aspx . Accessed 07 July 2012.

8. Casey PS, Goolsby C, Berkowitz C, et al. Maternal depression, changing public assistance, food security, and child health status. Pediatrics. 2004;113: 298304. 9. Marjerrison S, et al. Prevalence and associations of food insecurity in children with diabetes mellitus. J Pediatrics. 2011;158:607-611. 10. Parish S. Material hardship in US families raising children with disabilities. Exceptional Children. 2008;75(1):71-92. 11. Smith LA, et al. Employment barriers among welfare recipients and applicants with chronically ill children. Am J Public Health. 2002;92 (9):14531457. 12. Cook JT, Frank DA. Food security, poverty, and human development in the United States. Ann NY Acad Sci. 2008;1136:193-209. 13. Martin KS, et al. Social capital is associated with decreased risk of hunger. Social Science & Medicine. 2004; 58:26452654. 14. Jyoti DF, Frongillo EA, Jones SJ. Food insecurity affect school childrens academic performance, weight gain, and social skills. J Nutr 2005;135(12):2831-2839. 15. Cook JT, Frank DA, Berkowitz A, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutrition. 2004;134:14321438. 16. Alaimo K, Olson CM, Frongillo EA Jr, et al. Food insufficiency, family income, and health in US preschool and school-aged children. American Journal of Public Health. 2001;91(5):781-786. 17. Weinreb L, et al. Hunger: Its impact on childrens health and mental health. Pediatrics. 2002; 110(4):e41. 18. Kirkpatrick SI, McIntyre L, Potestio ML. Child hunger and long-term adverse consequences for health. Arch Pediatr Adolesc Med. 2010;164(8):754-762. 19. Park K, Kersey M, Geppert J, et al. Household food insecurity is a risk factor for iron-deficiency anaemia in a multi-ethnic, low-income sample of infants and toddlers. Public Health Nutr. 2009;12(11):2120-2128. 20. Grantham-McGregor S, Ani C. A review of studies on the effects of iron deficiency on cognitive development in children. J Nutr. 2001;131(2 Suppl):649S666S. 21. Lozoff B, Brittenham GM, Wolf AW, et al. Iron deficiency anemia and iron therapy effects on infant developmental test performance. Pediatrics. 1987;79:981995. 22. Halterman JS, Kaczorowski JM, Aligne CA, et al. Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States. Pediatrics. 2001;107: 13811386. 23. Eicher-Miller H, Mason A, Weaver C, et al. Food insecurity is associated with diet and bone mass disparities in early adolescent males but not females in the United States. J Nutr. 2011;141(9):1738-1745. 24. Rose- Jacobs R, et al. Household food insecurity: associations with at-risk infant and toddler development. Pediatrics. 2008;121:65-72. 25. Zaslow M, et al. Food security during infancy: implications for attachment and mental proficiency in toddlerhood. Matern Child Health J. 2009;13(1):66-80. 26. KleinmanRE, Murphy JM, Little M, et al. Hunger in children in the United States: potential behavioral and emotional correlates. Pediatrics. 1998;101: E3.

27. Murphy JM, Wehler CA, Pagano,ME, et al. Relationship between hunger and psychosocial functioning in low-income American children. J Am Acad Child Adolesc Psychiatry. 1998;37: 16370. 28. Alaimo C, Olson CM, Frongillo EA. Family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents. J. Nutr. 2002. 132:719725. 29. Winicki J, Jemison J. Food insecurity and hunger in the kindergarten classroom: its effect on learning and growth. Contemporary Economic Policy. 2003;21(2): 145-157. 30. Feinberg E, et al. food insecurity and compensatory feeding practices among urban black families. Pediatrics. 2008;122:e854e860. 31. Bronte-Tinkew J, et al. Food insecurity works through depression, parenting, and infant feeding to influence overweight and health in toddlers. J Nutr. 2007;137: 21602165. 32. Eisenmann JC, et al. Is food insecurity related to overweight and obesity in children and adolescents? A summary of studies, 1995-2009. Obesity Review. 2011;12(5):e73-83. 33. Karnik A, et al. Food insecurity and obesity in New York City primary care clinics. Med Care. 2011;49: 658661. 34. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004; 79(1):6-16. 35. Holben DH, American Dietetic Association. Position of the American Dietetic Association: food insecurity in the United States. J Am Diet Assoc. 2010;110(9):13681377.

RESOURCES
1. FRAC (Food Research and Action Center) The Food Research and Action Center (FRAC) is the leading national nonprofit organization working to improve public policies and public-private partnerships to eradicate hunger and undernutrition in the United States. FRAC works with hundreds of national, state and local nonprofit organizations, public agencies, corporations and labor organizations to address hunger, food insecurity, and their root cause, poverty. FRAC pursues a comprehensive national, state and local strategy, including: conducts research to document the extent of hunger, its impact, and effective solutions seeks improved federal, state and local public policies that will reduce hunger and undernutrition monitors the implementation of laws and serves as a watchdog of programs provides coordination, training, technical assistance and support on nutrition and anti-poverty issues to a nationwide network of advocates, service providers, food banks, program administrators and participants, and policymakers conducts public information campaigns to help promote changes in attitude and policies. 2. Hunger Free Vermont - Health Professionals Hunger Education Project Childhood Hunger in Vermont: The Hidden Impacts on Health, Development & Wellbeing.
https://hungerfreevt.globalclassroom.us/portal/ http://frac.org/about/

Health professionals have a unique opportunity to intervene and help ensure access to adequate nutrition for children, if they have the right tools. Hunger Free Vermont offers this course to help health professionals learn about hunger and how to help children and their families. This course, available online, is a 1-hour accredited tutorial that focuses on the impacts of childhood hunger and provides healthcare professionals with the information and tools for screening and intervention. Although the course is specific to Vermont, the general concepts and tools are useful for anyone.

Nutrition Focus Vol. 27 #3

13

May/June 2012

The course is divided into five modules: Introduction and overview How we got here, how we measure hunger, and what puts families at risk. What are food insecure families eating? What difficult choices are they forced to make? The profound effects of food insecurity on child health, development & education. What can you do? What is your role? 3. Oregon State University- Childhood Food Insecurity: Health Impacts, Screening, and Intervention
http://ecampus.oregonstate.edu/workforce/childhood-food-insecurity/

The Childhood Hunger Initiative (CHI) of Oregon, in partnership with OSU Extended Campus, has developed a free online and paper-based course with optional continuing medical education credits. Although this is a course primarily intended for MDs, it is open to all who want to take the course and provides excellent and clear information and additional resources regarding this topic. The Childhood Food Insecurity course is divided into five modules and each module takes about 10 minutes to complete. The modules include: Introduction and overview Food insecurity: definitions, measurement, prevalence, and predictors Food access and food choices: complex issues Food insecurity: relationship to child health and development Intervention strategies 4. Childrens HealthWatch
http://www.childrenshealthwatch.org/

Childrens HealthWatch monitors the impact of economic conditions and public policies on the health and well-being of very young children. The network of pediatricians and public health researchers collects data on children up to the age of three in emergency rooms and clinics in 5 locations around the US ( Boston Medical Center, the University of Maryland School of Medicine in Baltimore; the University of Arkansas for Medical Sciences in Little Rock; Hennepin County Medical Center in Minneapolis; and St. Christophers Hospital in Philadelphia) Childrens HealthWatch has produced many policy briefs and research to link nutrition, housing, energy and other policy issues to childrens health and development. Their mission is to improve child health by bringing evidence and analysis from the front lines of pediatric care to policy makers and the public. 5. USDA- Food Assistance Programs
http://www.fns.usda.gov/fns/

USDA (United States Department of Agriculture) is the government program that administers most of the federally funded food programs. Each program has specific population groups and eligibility guidelines. On this website is in depth information about each program as well as a wealth of information for professionals and consumers alike. 6. 2-1-1
http://www.211.org/

2-1-1 provides free and confidential information and referral. A person can call 2-1-1 and speak with someone who can help them get information and referral assistance with food, housing, employment, health care, counseling and more. It is a free service and is funded by local United Ways, community foundations and federal and local government funds.

NUTRITION FOCUS is published online six times per year by the Nutrition Section at the Center on Human Development and Disability, University of Washington. Subscription Rate and payment - Annual subscription rate is $45.00 and must be prepaid to the University of Washington. Credit card payments can be made online. Or, mail your payment (payable to the University of Washington US Funds), name, complete address and phone number to the editor. Some printed back issues are available, and online archives are available to all current subscribers. Continuing Education Credit Two hours of continuing education credit from the Commission on Dietetic Registration of the American Dietetic Association are available starting with the May/June 2011 issue. Subscribers will pay $20 per issue to obtain credit. Non-subscribers can also receive credit at the cost of $40 per issue. The CE quiz will be provided online at our website with a certificate for successful completion. The quiz is in each issue for you to review while you are reading. View our web page: http://depts.washington.edu/nutrfoc/webapps/ Resources/Comments/Topic Ideas - To share resources, comments and topic ideas please contact the Editor: Sharon Feucht, MA, RD, CD, Nutrition Focus CHDD-University of Washington Box 357920, Seattle, WA 98195-7920. Phone: 206-685-1297; FAX: 206-598-7815 email: sfeucht@uw.edu Current subscription or renewal questions Please address these to the Nutrition Focus Subscription Manager: Nancy Saunders CHDD-University of Washington Box 357920, Seattle, WA 98195-7920. Phone: 206-616-3831; FAX: 206-598-7815 e-mail: charbert@uw.edu

Nutrition Focus Vol. 27 #3

14

May/June 2012

Continuing Education Opportunity

To participate in this continuing education opportunity login to http://depts.washington.edu/nutrfoc/webapps/?page_id=739 to access the quiz related to this issue. You must correctly answer 80% of the questions to pass. Cost is $20 (subscribers) or $40 (non-subscribers) for 2 CPEU. 1. Which of the following best describes food insecurity? a. Limited or uncertain availability of nutritionally adequate and safe food resulting in disrupted eating patterns and reduced intake b. Lack of consistent supply of food due to economic constraint resulting in reduced quality, variety and desirability of diet c. Neither of the above d. Both of the above 2. According to the article, in 2010 food insecurity or lack of consistent supply of nutritionally adequate food was reported by what percent of US households with children: a. 10% b. 14.5% c. More than 20% d. 39% 3. Which of the following statements about iron deficiency anemia (IDA) is true: a. IDA has been associated with cognitive deficits, but not psychomotor b. If IDA is treated within the first three years, cognitive deficits can be reversed c. Children from food insecure households are twice as likely to experience IDA than children whose households were food secure d. IDA is more common among boys from families with food insecurity than without, but there are no differences between girls from food secure and insecure families 4. Children between 6 and 12 years of age who were categorized as hungry were more likely to have clinical levels of psychosocial dysfunction as measured by the Pediatric Symptom Checklist. Which of the following was NOT listed as a problem: a. Aggression b. Behavioral problems c. Academic problems d. Obsessive compulsive disorder 5. A longitudinal study found that: a. Children who have ever experienced hunger have poorer health over the ensuing 5-10 years b. As long as food insecurity is mild and resolves within 2 years, there are no long-term effects c. Younger children experience more negative long-term effects of food insecurity than older children d. Hunger is associated with significant short-term effects (e.g., aggression, depression), but fewer long-term effects (e.g., chronic conditions such as asthma) 6. Which of the following contributes to risk of food insecurity: a. Poverty b. Social isolation c. Mental health issues such as depression d. All of the above 7. Which of the following approaches to discussing food security with families is suggested by this article: a. Ask: Do you have enough money to buy the right foods for your child? b. Ask: Many families find it hard to make ends meet at the end of the month, would you like information about other food resources? c. Provide a comprehensive list of community resources to all families d. Dont ask about resources; families may feel like the practitioner is suggesting that they do not know how to care for their child from symptoms is present before 3 years of age 8. Health care providers: a. May become aware of potential problems (e.g., recent job losses or additional expenses) through casual conversation b. Should screen for food insecurity and share information or make referras to appropriate programs as part of their jobs c. Should consider resources when making recommendaitons and be aware of available programs (e.g., suggest foods and/or modifications to foods that may be available through WIC or local food pantries) d. All of the above 9. Which of the following programs provides direct payments in the form of electronic benefits redeemable at most retail food stores: a. CSFP (Commodity Supplemental Food Program) b. NSLP (National School Lunch and related programs) c. SNAP (Supplemental Nutrition Assistance Program) d. TEFAP (Temporary Emergency Food Assistance Program) 10. Hunger Free Vermonts Food and Nutrition Screening Algorithm identifies several actions providers can take. These include all of the following EXCEPT: a. Discuss/share information about resources at enrollment b. Check back about hunger or nutrition concerns at each visit c. Be familiar with local food resources and inform families d. Refer all families to food and hunger related resources

Nutrition Focus Vol. 27 #3

15

May/June 2012