by ChrisAnna M. Mink, M.D.
No school today, so no lunch. Nine-year-old Marilyn and her mom, Maria Villa, are cleaning their porch and discussing what to cook for their only meal today. Perhaps, soup with rice and beans. No meat, no veggies.
Marilyn is petite with expressive chestnut eyes, long brown hair that’s barely combed and the slightest of smiles. If she could eat anything, it would be fruit, especially apples and bananas, but these are treats – they’re too expensive to have everyday.
The Villa Family live in Wilmington in an apartment in a strip of six single-units that looks like an emaciated 1960’s roadside motel; all of the correct structures are present, just shrunken. The tiny patio is cluttered with broken toys, baseball bats, recyclable bottles and a wire bookcase covered with leafy green foliage. The plants are Maria’s pride – she insists flowers and children make a home.
Marilyn happily sweeps away leaves, though no trees are nearby, and talks to her adopted stray cats and two Chihuahuas. Add a Disney tune, and this could easily be a scene from Cinderella, but before the Fairy Godmother arrives.
Marilyn is the youngest of nine children; she is a patient in the general pediatrics clinic and Pedro, her 13-year-old brother sees specialists at Harbor-UCLA Medical Center. The family has always struggled, but things got worse when her dad was injured in a work accident more than one year ago. While he was on disability, his position was terminated. The family is getting by monthly on Maria’s $945 income and $400 from CalFresh, which is slated to increase to $900 since their dad is incapacitated. After they pay rent and utilities, their daily food budget is what most of us spend on a Mocha Frappuccino.
Like more than one million Angelenos, Marilyn and her family are food insecure. That’s the government’s euphemistic term for people who don’t have enough food to lead normal healthy lives. Food insecurity has risen to the forefront of national debate because so many Americans are affected. Despite the economic recovery, 21% of US children live in poverty. Some of those affected are our patients.
Harbor-UCLA is located in Los Angeles County’s South Bay, which encompasses one of the most ethnically, culturally and economically diverse regions in the US. Rancho Palos Verdes and Manhattan Beach are two of the wealthiest cities in the country. With so much affluence and natural beauty, the area’s impoverished communities are often overlooked. But many of our neighbors, like the Villas live with hunger – 36.9% of the area’s poorest residents (those living 300% or more below the federal poverty level) simply don’t have enough food.
The Villa family learned about food programs from their doctors at Harbor. Pedro who is neurologically impaired and cannot walk, talk or even eat. All of his nutrition comes from an enriched liquid delivered directly into his stomach through a special tube. Pedro was born in San Pedro and was a happy, healthy baby until he started having intractable seizures at age four months. His development came to a complete stop, and like any infant, he remains dependent upon his mom for survival. Pedro’s condition also impaired his growth, a term called failure-to-thrive or FTT. Because of his poor growth, Pedro’s neurologists referred him to FTT Clinic at Harbor.
Dr. Carol Berkowitz is an internationally renowned expert in child nutrition and maltreatment. She established the clinic in 1980 after noticing the frequency of ER referrals for evaluation of underweight children. “Its important to look at all aspects of child’s life when evaluating
The FTT clinic provides comprehensive, multi-disciplinary care for children who aren’t growing as expected. The core team includes a nutritionist, Sheri Lovall, a pediatric nurse practitioner with expertise in child abuse and neglect, and Olga DeJesus-Varga, clinic coordinator. The team consults with other services, such as social work and psychology, when needed.
De Jesus-Varga has been the coordinator for the FTT Clinic for nearly 20 years. She has a master’s degree in Public Health and has worked with food assistance programs for most of her career, including in the Peace Corps. “Too many families are struggling,” said De Jesus-Varga, “ They just don’t have enough money to feed their kids.”
Pedro’s slow growth is related to his underlying neurologic disorder, but most of the children seen in FTT do not have organic disorders. Berkowitz has found that inadequate food in the house and psychosocial problems, including maternal depression and disrupted parent-child relationships are common.
Maria believes FTT Clinic saved her whole family, not just Pedro, from going hungry because the team taught her about government and community resources. Maria can name all of the food banks within the Wilmington and Harbor Gateway communities, but she says, “I only go to one a week because other families need food too.”
De Jesus-Varga’s duties include serving as a promotora, a community outreach educator. She does home visits and teaches her FTT families about grocery shopping, meal preparation and how to make affordable, healthy food choices. At home visits, she discusses the families’ finances and notes if they have refrigerators, cabinets or any food in their living quarters. Some impoverished families live in rented rooms and those essentials are missing. She also observes how an FTT child is behaving – underfed kids may show extremes, from withdrawn and lethargic to irritable and uncontrollable. Stressed parents and misbehaving, hungry children is a set-up for child abuse. The FTT team works with the families to find resources before something bad happens. “But the Villa’s, they’re different” said De Jesus-Varga, “They have nothing [in material possessions], but never complain or seem angry.”
I joined DeJesus-Varga for a home visit to the Villas, when she was helping Maria, Marilyn and Jennifer, a 16-year-old sister plan for grocery shopping. “Sometimes I do go home in tears,” says De Jesus-Varga after the visit, “These girls are smart. Just imagine what they could become if they get the opportunity. How can they learn at school if they’re distracted by hunger?” She expresses gratitude for food programs because they are the only hope for some kids.
The government has safety net programs to address food insecurity: Supplemental Nutrition Assistance Program (SNAP is a federal program, formerly food stamps), CalFresh (California’s SNAP program), and Women, Infants and Children (WIC), which provides assistance for pregnant women and children younger than 5 years. The food programs account for approximately $135.7 billion (3.5%) of the total federal budget.
The Healthy, Hunger-Free Kids Act of 2010, which encompasses nine food safety net programs including school lunch and WIC, expired in 2015. On January 20, the Senate Agriculture Committee cleared the law now named, Improving Child Nutrition Integrity and Access Act of 2016. This legislation would reauthorize the nutrition programs; next, it goes before the full senate. Most of the programs are permanently authorized, but every five years congress reviews the laws to assure that they are meeting current nutritional standards, as set by the Institute of Medicine, a non-partisan panel of health and nutrition experts.
Currently, more than 48 million Americans rely on SNAP to get by. To qualify, a four-member family’s annual income needs to be less than $31,000. The average household incomes in four South Bay neighborhoods (Harbor Gateway, Harbor City, San Pedro and Wilmington) are less than $50,000.
In metropolitan L.A., food insecurity disproportionately affects communities of color. Nationally, more than half of SNAP recipients are Caucasian and two-thirds of households with hungry kids have at least one working parent. Wages are low compared to the cost of feeding a family.
SNAP provides about $1.50 per person per meal, and most families run out of money before getting their next installment. “At the end of the month, we don’t have enough for everyone,” says Jennifer, “so we go to food banks.” She knows that St. Peter and Paul Church, just a few blocks away, hosts a food pantry on Wednesday. No fresh food, but they can get beans, rice and cereal to make it through the end of the month.
Paradoxically, obesity is the partner of hunger. More than one-third of 4-year-old WIC recipients are overweight or obese. Affordable food is frequently highly processed and calorie-dense but low in nutritional value. A box of mac’n’cheese is really cheap and makes tummies feel full, but it’s low in nutrients, so the unused calories get stored as body fat.
While food banks provide a lifeline for famished families, many of their donations are pre-packaged or highly processed staples, with few fresh produce options. But farmers, food pantries and volunteers are cultivating change.
Gathering produce in the field after farmers have completed their harvests, called gleaning, has become a popular source for rescuing fruits and vegetables for food banks. Food Forward, a philanthropic group based in North Hollywood, works with local farmers to deliver their crop excess to service agencies in Los Angeles and Ventura Counties. Torrance Farmers Market is now a participant with Food Forward, with the collected produce going to local food banks. Harbor-UCLA hosts a weekly farmers market on campus, helping to provide access to fresh fruits and vegetables for our families.
Locally and nationally, many organizations are working to solve food insecurity.
Some Hollywood A-listers, including Jeff Bridges, have used their celebrity and checkbooks to respond to the grumble of their hungry neighbors. For nearly three decades, Bridges has been working to fight hunger, at first globally and now nationally. In 2010, he became the spokesperson for No Kid Hungry, a program under Share our Strength, dedicated to ending childhood hunger in the US.
Bridges’ latest efforts have been devoted to funding breakfast in schools. When speaking at a “Breakfast After the Bell” event at Stanley Mosk Elementary School in Winnetka, Bridges said, “ We’ve got too many kids coming to school too hungry to learn. We have to feed these kids.” Working with the L.A. Fund for Public Education, he has helped increase the number of schools in the L.A. Unified School District serving breakfast from 30% to more than 80%. Breakfast matters. In schools with breakfast programs, attendance and math test scores improve. Kids who aren’t hungry learn better.
Local governments are also cooking up solutions – last spring, Los Angeles City Council proposed an increase in the minimum wage. In July, L.A. County supervisors voted to increase the minimum wage for the unincorporated areas of the county. KPCC radio reported that with both the city and county planning the raise; about 50 percent of workers in L.A. County should receive pay at a $15 minimum wage by 2020. It is not yet known if incorporated cities in the South Bay will follow.
Pediatricians are on the front lines and see the adverse health effects of food insecurity and are doing their part to fight against childhood hunger. In November 2015, The American Academy of Pediatrics (AAP) released a policy statement, “Promoting Food Security for All Children.” The AAP recommends that pediatricians screen for hunger by incorporating the two questions below into scheduled health maintenance visits:
1. Within the past 12 months, we worried whether our food would run out before we got money to buy more.
2. Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.
Affirmative answers to these questions have 97% sensitivity for identifying families with limited food. This information also provides insight about the families’ stress level and overall wellbeing, essential for assessing a child’s health. The policy also encourages pediatricians to become familiar with community resources and to embrace their roles as child advocates at local, state and federal levels of government.
Pediatricians can also be influential in their community by volunteering in programs, such as gleaning projects, food banks and soup kitchens, as well as serving on the boards of local non-profit organizations.
With commitment from multiple organizations, government programs and pediatricians, families like the Villas, should no longer have to fend off hunger and instead be able to nurture their children to achieve their full potential.
Postscript
Berkowitz and the FTT team welcome referrals from specialists, child protective services and the community. They rely upon donations and grants to provide additional resources, such as grocery coupons, for their hungry patients. For referrals or to make a donation, please call 310-222-3091.
PHOTO CAPTIONS
1. Failure-To-Thrive Clinic Team: Dr. Carol Berkowitz, director, Sheri Lovall, pediatric nurse practitioner, and Olga De Jesus-Varga, clinic coordinator.
2. Olga De Jesus-Varga, FTT clinic coordinator, with Marilyn (age 9 years) and Maria Villa during a home visit.