PBH 805: Week 8 Slides

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Week 8
Chapter 13
Instructor: Gina Crosley-Corcoran, MPH
PBH 805 – Maternal & Child Health

Introduction
 Nutrition is a critical component of the health status of the MCH
population across the life course.
 Early childhood health is inherently reliant on maternal health due
to children’s limited self-efficacy and agency before age 5.
 Inadequate nutrition before and during pregnancy, and during
early childhood, can affect a child’s cognitive development.
 The concept of linked lives remains relevant as family purchasing
and mealtime practices continue to influence child nutrition during
childhood and adolescence.

Malnutrition in the United States
(1 of 2)
Several terms are used interchangeably to describe inadequate access
to food.
Phenomenon Definition
Food insecurity
The limited or uncertain availability of nutritionally
adequate and safe foods or the limited or uncertain ability
to acquire acceptable foods in socially acceptable ways.
Hunger
The uneasy or painful sensation caused by a lack of food,
the recurrent and involuntary lack of access to food.
Undernutrition
A condition brought about by insufficient intake of nutrients
to meet biological requirements.
Republished with permission of The National Academies Press, from Food Insecurity and Hunger in the United
States: An Assessment of the Measure. (2006); permission conveyed through Copyright Clearance Center,
Inc.
Table 13-1: Definitions of Concepts Relating to Lack of Food and Resulting Consequences

Food Security
Category
Subcategory Definition
Food security High food security
No reported indications of food-access
problems or limitations.
Food security
Marginal food
security
One or two reported indications—typically of
anxiety over food sufficiency or shortage of
food in the house. Little or no indication of
changes in diets or food intake.
Food insecurity Low food security
Reports of reduced quality, variety, or
desirability of diet. Little or no indication of
reduced food intake.
Food insecurity
Very low food
security
Reports of multiple indications of disrupted
eating patterns and reduced food intake.
Table 13-2: Food Security and Insecurity Subcategories
USDA added categories to represent spectrum of food security.
Malnutrition in the United States
(2 of 2)

Key Historical Federal Nutrition Policies
(1 of 3)
1930: USDA
distributes
surplus
agricultural
commodities
as food relief.
1946: National
School Lunch
Program (NSLP)
1954: The
Special Milk
Program aims
to increase
milk
consumption
at school.
1964: Congress
establishes the
National Food
Stamp Program
(NFP).
1966: Child
Nutrition Act,
includes school
breakfast

(2 of 3)
1968: Special Food Service
Program for Children is
established, becoming the
foundation for Summer Food
Service Program (SFSP) and
Child and Adult Care Food
Program (CACFP).
1972: Congress authorizes
Special Supplemental Food
Program for Women, Infants,
and Children (WIC).
1981–1982: Congress passes
the Omnibus Budget
Reconciliation Act, Omnibus
Farm Bill, and Tax Equity and
Fiscal Responsibility Act,
which eliminate, restrict, and
reduce food and income
benefits.

(3 of 3)
1988: The U.S.
Department of
Health and Human
Services publishes
the Surgeon
General’s Report on
Nutrition and
Health.
1991: The Mickey
Leland Childhood
Hunger Relief Act.
1995: The USDA
begins to measure
food insecurity
nationally.
2009: Changes to
WIC improve
healthfulness of the
WIC package,
including fresh
fruits and
vegetables and
whole grains
2010: Congress
authorizes the
Healthy, Hunger-
Free Kids Act,
updating nutrition
standards for school
meals and
expanding access to
school meals.

Recent Trends in Food Insecurity
(1 of 2)
 As of 2018, the U.S. had reduced national levels of household food
insecurity from a peak of 14.9% in 2011 to 11.1% in 2018.
 This marked the first-time food insecurity fell below pre-recession
level (2007).
 However, rates are still higher than the Healthy People 2020 goal
of 6%.

Recent Trends in Food Insecurity
(2 of 2)
Inequities
in food
insecurity
persist:
Black, Hispanic, and Native American households have
experienced chronically higher rates of food insecurity
compared to White households.
People with disabilities are more likely to be food insecure
than people without disabilities.
Households with children and households with children and
a single parent have higher than average food insecurity.
Households below 185% poverty have the highest rates of
food insecurity across income groups.

Impact on Growth, Development, and Health
(1 of 2)
Food insecurity and poverty
negatively impact children’s
growth and development
and, subsequently, their
health across the life span.
Poverty is associated with
inadequate quantities of
food, poor diet quality,
lower dietary diversity, and
inadequate intake of
micronutrients.
Pregnant women with food
insecurity have higher risk of
micronutrient deficiency
and poor maternal mental
health outcomes.

Impact on Growth, Development, and Health
(2 of 2)
Infants and young children with
poor diet quality may have
micronutrient deficiencies and
inadequate protein intake, which
may limit physical growth and
cognitive and socioemotional
development.
School-age children in food
insecure households have lower
math and reading scores, are
more likely to repeat a grade,
are more likely to have seen a
psychologist, and are less likely
to get along with peers.
Among adult women, food
insecurity is associated with
obesity.

Overnutrition
Obesity is a chronic energy imbalance in which energy
intake continually exceeds energy output.
• Overweight (BMI >85th percentile)
• Obesity (BMI >95th percentile)
Childhood obesity is measured with body mass index
(BMI).
• Overweight among all children age 2 to 19 is 16.6%
• Obesity among all children age 2 to 19 is 18.5%
• Obesity among Hispanic children is 25.8%
• Obesity among Black children is 22.0%
U.S. has highest rates of childhood obesity in the world.

Obesity Risk Factors
Prenatal
maternal
health
Smoking
Obesity
High glucose levels
Total gestational weight gain
Nutrition
during
childhood
Increased caloric intake
Increased portion sizes
Sugar-sweetened beverages
Environments Communities with low access to supermarkets
Communities with low SES households
Neighborhoods with higher numbers of fast food and convenience stores

Obesity Consequences
 Children who are obese are more likely to
 Face bullying and discrimination
 Develop comorbidities, such as diabetes and cardiovascular disease
 Become obese adults
 Need further understanding of complex interplay of nutritional,
behavioral, and environmental factors to decrease the prevalence
of childhood obesity.

Public Health Nutrition Guidelines
The Dietary Guidelines for Americans (DGAs) were first
published in 1980 and they are updated every 5 years.
The 2020 DGAs provide the basis for federal nutrition
programs (e.g., NSLP) and they are a reference for clinicians.
In 2015 and 2020, DGAs shifted from “nutrient-based” to
“food-based” that focus on patterns of food consumption
rather than key levels of macronutrients and micronutrients.

The MyPlate Food Guide
<Insert Figure 13-2>

2020 Dietary Guidelines for Population
Health
Follow a healthy
dietary pattern at
every life stage.
Customize and enjoy
nutrient-dense food
and beverage choices
to reflect personal
preferences, cultural
traditions, and
budgetary
considerations.
Focus on meeting
food group needs
with nutrient-dense
foods and beverages,
and stay within
calorie limits.
Limit foods and
beverages higher in
added sugars,
saturated fat, and
sodium, and limit
alcoholic beverages.

Nutrition Recommendations for MCH Populations
(1 of 2)
 Maternal nutrition
 Pregnancy and lactation are critical periods within the life course.
 Families should aim for women to conceive when they are at a healthy
BMI and follow IOM weight-gain recommendations.
Pre-pregnancy Weight
Category
Body Mass Index (kg/m2) Recommended Range of Total
Gestational Weight Gain (lbs)
Underweight Less than 18.5 28—40
Normal weight 18-5—24.9 25—35
Overweight 25—29.9 15—25
Obese 30 or greater 11—20
Table 13-4: Institute of Medicine’s Weight Gain Recommendations for Pregnancy

Nutrition during pregnancy
• Increases in energy, micronutrient, and macronutrient intake are required
during pregnancy.
• Energy/calorie increase is required during the second and third trimesters.
Nutrition during lactation
• Breastfeeding women require 500 additional calories per day.
• Carbohydrates provide a major energy source for milk production.
• Lactating women need to continue taking a prenatal vitamin to avoid
deficiencies in micronutrients.
• Continue limiting high-mercury fish and caffeine, both of which can pass to
the baby.
Nutrition Recommendations for MCH Populations
(1 of 2)

Breastfeeding/Chestfeeding
(1 of 3)
Benefits for baby
• Optimal growth and
development
• Human milk
contains antibodies
and other elements
that promote
immune system
development and
protect from
common illnesses
• Promotes healthy
attachment
Benefits for birthing
person
• Prevent post-
partum
hemorrhage
• Promote uterine
involution
• Lower risk of post-
partum depression
• Lower risk of heart
disease and
reproductive
cancers

(2 of 3)
Breastfeeding rates in
the U.S. fall below WHO
and AAP standards.
Of Babies born in the U.S. in 2015...
•83% introduced to breastmilk
•58% breastfeeding at 6 months old
•36% breastfeeding at 12 months old
•50% exclusively breastfeeding at 3 months
•25% exclusively breastfeeding at 6 months

(3 of 3)
Barriers to breastfeeding
Difficulties breastfeeding
(e.g., pain, discomfort)
Work-related stress
Sleep deprivation
Lack of social support
Characteristics associated
with lower rates of
breastfeeding initiation,
exclusivity, and duration:
Young age (age 18–24)
Income less than 185% FPL
Non-White
Less than a college degree
Living in the South or
Midwest

Complementary Feeding
When breastmilk or formula alone
cannot meet nutritional needs of
baby
Typically about 6–24 months old
At 8 months old, infants can eat
“finger foods.”
By 12 months, most typically
developing infants can eat the same
foods as the rest of their family.

Complementary Feeding
Feeding styles should support infant self-
regulation by allowing infant to self-feed
when ready.
WHO recommends parents practice
responsive feeding, limiting distractions
during mealtimes and responding
appropriately to child’s hunger and satiety
cues.
How infants are fed is essential in shaping
appetite regulation and reducing obesity
risk.

Child Nutrition
 DGAs do not provide separate guidelines for children after
age 2.
 Healthy eating patterns important for optimal development.
 Most children age 2–19 in the U.S. consume:
 Too much sodium
 Too little whole grains
 Too little fruits and vegetables
 Inequities
 Adolescent diets are worse than diets of younger children.
 Black and Mexican youth have lower-quality diets than White
children.
 Child diet quality increases with parent education.

Public Health Nutrition Programs
(1 of 4)
Special Nutrition Assistance
Program (SNAP)
35 million people
received benefits in
2019
• Entitlement program
based on income-
eligibility
• 130% FPL ($34,000 for a
family of 4)
Average benefit is
$129 per person per
month
SNAP effectively
reduces food
insecurity.
SNAP has not been
shown to improve
diet quality or weight
status.

(2 of 4)
Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC)
WIC began in
1975
States set income
eligibility (100–
185% FPL)
Evidence that
WIC participation
improves diet
quality and
weight status
Participation has
declined from
63% of eligible
individuals in
2011 to about
50% currently.

(3 of 4)
School nutrition programs
National
School
Lunch
Program
The School
Breakfast
Program
The At-Risk
Afterschool
Meals
Program
Summer
Food
Service
Program
Child and
Adult Care
Food
Program

(4 of 4)
More than half of children
in public schools participate
• 30 million out of 50 million
participate in NSLP
Participating children
receive 25–33% of their
daily calories from school
nutrition programs
Healthy and Hunger Free
Kids Act (2010) improved
school nutrition standards
by requiring fruits,
vegetables, whole grains,
and limited sodium.
Community Eligibility
Provision allows school
districts with high levels of
eligible children to serve all
children free of cost.

Conclusion
Mothers, children, and families in the U.S. face challenges in meeting
nutritional needs.
Food insecurity and obesity are major challenges.
Federal programs are critical for supporting healthy nutrition across the life
course.
Multi-level interventions are needed to address the complexity of multiple,
interacting elements involved in both food insecurity and obesity.
Strengthening federal nutrition programs can support community health.

Week 8 Assignments
Problem
Statement
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PBH 805: Week 8 Slides

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