But symptoms like those can have many causes. In more than 30 years as a pediatrician, Handler never once asked a family whether they might be caused by hunger.
“When you have somebody come to your clinic, you’re looking for clinical causes, diagnosis of disease,” said Handler, who is now the public health officer for Orange County, Calif. “Very rarely do we even consider hunger as being an issue causing a problem. And yet there are multiple health concerns one can have when you’re hungry.”
In fact, a growing body of research from the National Institutes of Health suggests there are few things that could warp a child’s health more than “food insecurity,” which is the term used by the U.S. government to classify families that don’t know where their next meal is coming from.
Studies suggest that hunger — even if it’s only experienced for brief periods during childhood and adolescence — can lead to outcomes that last a lifetime, including early-onset diabetes, high blood pressure, cardiovascular disease, stunted intellectual growth and obesity. Other findings point to even more surprising effects, like tooth decay and early menstruation in girls.
Nearly 50 million Americans don’t always have access to the food they need to lead healthy and productive lives — 17 million of them children, according to the anti-hunger group Feeding America. Even more startling: About half of the kids in the U.S. rely on food stamps at some point during childhood.
One of the worst places for such widespread hunger, especially among children, is Orange County, Calif. Despite its reputation for extreme wealth and privilege — one made famous by show like “The OC” and “The Real Housewives” — the county is also home to more than 150,000 children who don’t always have the food they need to grow properly. That’s 1 in 5 children in the county.
It’s not because there’s an absence of food, according to Mark Lowry, the director of the Orange County Food Bank. It’s largely tied to the county’s high cost of living — which is so steep that low-income workers often struggle to pay for basic needs, including food.
“So the ‘real’ housewives of Orange County are the people that we serve each month,” Lowry said. “There are a few who enjoy a very rich lifestyle here, but there are many more who are seniors on fixed incomes, disabled, unemployed or among the working poor.”
And while the Orange County Food Bank helps about 165,000 people with emergency food each month, there are about 235,000 more in desperate need of assistance.
So Lowry has teamed up with Dr. Handler and a coalition of other major players from the county to form the “Waste Not OC coalition.” The goal: to collect the un-served perishable food being thrown away at the end of the day by restaurants, hotels, sports centers and theme parks in the county, and then redirect it safely to those in need.
Lowry admits that the logistical challenges of collecting, packaging and re-distributing large volumes of perishable food remains massive. But he also said that a coalition of this kind — especially one driven by the local health care agency — “absolutely” has the potential to end hunger. “Considering that we discard 40 percent of our food, if we’re able to capture some substantial percentage of that food, it’s going to address people’s nutritional needs,” he said.
On the consumer end, the “Waste Not, Want Not OC” coalition has developed an interactive map to point hungry families toward food banks and other resources where they can collect some of this newly redirected food. The eventual goal is for doctors to incorporate questions about food access into primary care visits and then use the map to refer hungry families to the appropriate resources.
Letitia Clark George, the executive director of the Orange County chapter of the American Academy of Pediatrics, says it’s a move in the right direction from the days when doctors felt like their hands were tied even if they did recognize the symptoms of malnutrition. “A lot of the times,” she said, “doctors are hesitant about diagnosing a problem if they don’t have the resources to follow up with it. So this going to empower a lot of our pediatricians.”
Tune in to Friday’s PBS NewsHour broadcast for the full report on Orange County’s hunger problems — and its “Waste Not, Want Not” ambitions.
In the meantime, a closer look at the ties between hunger, obesity and stress — three things that go hand-in-hand for many low-income families. For that, we turn to Barbara Laraia, associate professor at University of California, Berkeley, who has been studying the effects of hunger for about 20 years.
The first thing to remember, she said, is that effects aren’t the same for everyone. “It is an interaction between the exposure, the intensity of exposure, and at what developmental period,” Laraia said. “But generally, food insecurity and poverty absolutely have a role in developing chronic disease.”
PBS NEWSHOUR: Barbara Laraia, thank you so much for joining us. Let’s start with the diet. Are there certain foods that are more prevalent in low-income households today?
LARAIA: When you look at dietary indicators, and what households are eating, we find that those who are food insecure are more likely to eat high calorie, dense foods — your chips, potatoes, processed meats — and much less fruits and vegetables. And it’s not hard to realize that it comes down to finances. Lean meats and fresh fruits and vegetables are much more costly and perishable. It’s easier to stretch your food dollars much further if you have the inexpensive, high-calorie, dense foods.
I also want to provide a little caveat, and say that all Americans right now are eating very poorly. Across the board, less than 20 percent of Americans meet the dietary guideline of having two fruits or three vegetables a day. Then we find that low-income families are much less likely to have fruits and vegetables and lean meat.
NEWSHOUR: And what are the health consequences — especially for children who may be experiencing hunger while growing?
LARAIA: We think that it’s really an interaction between when food insecurity is happening in the household and at what critical developmental period.
The animal studies are really suggestive of this. There’s a really interesting study with macaque monkeys, for example, where they stressed out the mom. So what they did was they set up a system, where sometimes the mom had food in her environment where she could find it, and sometimes they restricted the food — they put it in a foraging cart and hid it somewhere in the environment. And then there was a third paradigm, where, for two weeks, they would have enough food, followed by two weeks without enough food.
And so what happened was the moms that had this uncertainty really were stressed out, and they were more aggressive with the other female macaque monkeys. They were also less attentive to their offspring. And even though the baby macaques had enough food — because they eventually found the food in the environment — they had a spike in their stress response during this 16-week protocol. And that was associated with developing obesity in adolescence.
So at least one study, if not a couple studies, are showing that early life exposure to food insecurity and stress is associated with later weight gain. Not for everyone. It’s going to be a really stressful environment with food insecurity and compromised diet. That seems to be a recipe for that weight gain later on.
NEWSHOUR: Something else you believe may contribute to weight gain is the idea of the ‘food stamp cycle.’ Explain what that means.
LARAIA: Food stamps are provided once a month. So it’s possible that at the beginning of the month, when families have enough money — whether through their jobs or through food stamps — they purchase food for the month. And they might buy in bulk and try to stretch their food dollars as far as they can. They probably have more access to the fresh fruits and vegetables at that time. And then, over the month, as resources dwindle, there’s less of a variety of the diet. So whether calories are severely restricted or variety’s restricted, by the end of the month, families feel deprived. They’re psychologically deprived of food, they possibly are physiologically deprived of enough calories. Either way, that creates a stress response. And that might lead subsequently to overeating at the beginning of the month.
That’s considered the “food stamp cycle” — this cycle of having enough food or the perception of enough food at the beginning, followed by less food. There’s some direct evidence, and some anecdotal evidence, that there’s this kind of cyclical exposure to severe food insecurity, and that, possibly, can wreak havoc with one’s metabolism.
NEWSHOUR: So stress is a major factor. Why does that lead to weight gain?
LARAIA: We have this hormone called cortisol that tells the body when it needs to start to distribute glucose throughout the day and throughout the week. If the body needs more energy — and the body needs energy to do anything — cortisol is making sure that sugar and glucose levels are maintained. Under stress conditions, cortisol will spike and say, “OK, we need more glucose because we might need to run. We might need to activate something.”
Under those conditions, people will reach for that high-fat food — that cookie or the snack food, because we have found that high-fat, high-sugar food not only is ready energy, but it also dampens that stress response. It’s a reward food. It’s not the same as reaching for the apple.
So we have these stressful situations where the body’s saying, “I need some energy. Reach for the cookie.” And at this point in time in the United States, cookies and snack foods are everywhere. They’re at every corner store. They’re in Jo-Ann Fabrics and Best Buy, places that they were very unlikely to be 20, 30 years ago. So since we have those daily stressors — and food insecure families are susceptible to that same phenomenon, even more so — that stress response really leads to selecting those highly palatable, energy-dense foods. Not only is the income restriction leading to purchasing energy-dense foods, but it’s the stress, as well.
Additionally, we know that stress will really wreak havoc with the pre-frontal cortex, so the pre-frontal cortex — the front of your brain — is really the decision making process machine, and it really helps with reasoning. So the limbic system kicks into gear, and that is a system that’s more emotional; it’s going to reach for the highly palatable food. So stress and food insecurity play this really direct role in how food choices are made, and then, as we already spoke, the other system is really how it’s metabolized.
Evolutionarily, it just makes sense that you would reach for that ready energy and over-consume.
NEWSHOUR: And under those conditions, fat also may be metabolized differently, correct?
LARAIA: There was an elegant study in Minnesota, where mice who were stressed out by having to swim in lukewarm water and then introduced to junk food. They ended up eating a little bit more and accumulating a little bit of visceral fat. But mice subjected to swimming in cold water for an hour or being put in a cage with an alpha mouse, this was a very stressful condition, and it’s a stress that is a threat. The mouse accumulated an abundant amount of visceral fat. There was fat all throughout the organs.
What they found is that — for the mice who perceived a threat — energy was metabolized and turned into visceral fat. And that visceral fat is the more toxic fat, because it’s metabolically active and it’s sitting right around the organs. Evolutionarily, maybe this was really important to have active fat so that if you needed to run, you had fat stores that could be mobilized. But in today’s environment, this fat has become very toxic. We’re no longer being chased by the tiger and really need to access that fat. So eating in the presence of stress causes fat to be stored right around our midsections — and that’s been associated with obesity, diabetes and all kinds of chronic conditions.
NEWSHOUR: So all of these things combined mean that people can be both malnourished and obese at once, right? It’s a concept that can be hard to reconcile.
LARAIA: Right. You can imagine if someone is overeating highly processed foods that might not have enough iron and micronutrients, it can lead to gaining weight and not having enough of those important micronutrients — your vitamin A that comes from orange vegetables, vitamin C and iron are really important. And we definitely find when we look at food insecurity that it’s consistently associated with anemia in children, for example.
So I think being subjected to food insecurity, especially severe cases of food insecurity, where the family is going without food, skipping meals, having a limited variety of foods, and eating under those stressful conditions — that absolutely leads to the perfect storm of gaining weight possibly, developing chronic disease and it might be associated with later chronic disease for children.
NEWSHOUR: Are there particular moments in childhood when hunger is most dangerous?
LARAIA: There have been a few studies that show that by age 5, children are more likely to be overweight if they had the early life exposure to food insecurity. Pre-puberty is also an important time, especially for reproduction. If the person is perceiving that they’re food insecure, if they’re calorie-restricted or nutrient-restricted, and the body’s getting ready to be reproductive, then it makes sense that the body would accumulate fat to make sure that there’s enough energy stores for that process later on.
NEWSHOUR: Barbara Laraia, thank you so much for joining us.
LARAIA: Thank you.
This package was produced with support from The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School of Journalism, and the Dennis Hunt Fund for Health Journalism.