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Rx for the FutureChris Hartlove

Rx for the Future

David Paige's idea for "prescribing appropriate foods" in 1969 led to the federal program that now helps half of all infants in the U.S.

As a pediatric resident at Johns Hopkins Hospital and an MPH student in the late 1960s, David Paige was frustrated. Iron-deficient infants with stunted growth routinely arrived at the Harriet Lane emergency room-many so sick they required hospitalization. At the time, breastfeeding was rapidly declining in favor of evaporated milk formula, which poor families frequently would dilute with water to make it last. Some mothers gave infants cow's milk, which often led to gastrointestinal blood loss.

The solution pioneered by Paige, MD, MPH '69, and colleagues evolved into the federal Women, Infants and Children (WIC) nutrition program. WIC is the third-largest federal nutritional assistance program (after food stamps and school lunches). Designed to prevent the serious health consequences of malnutrition, it provides nutritious foods, nutrition education and referrals to health care and social services. Today, almost half of all U.S. infants and one-quarter of children aged 1 to 4 participate in the program.

The affable and energetic professor of Population, Family and Reproductive Health recently talked about WIC's origins and impact with Bloomberg School historian Karen Kruse Thomas, PhD.

Power of prevention.

In my public health courses, we learned that you prevent disease. You don't wait to treat it. I was really annoyed. I said, "I'm writing prescriptions for everything. Why don't we treat iron deficiency and undernutrition by prescribing appropriate foods?" That was really the dawning of the WIC issue for me. That clinical recognition of the futility in treating case after case.

In the School of Hygiene, I was taking a course on population statistics with Matthew Tayback [ScD '53], an assistant commissioner in the Baltimore City Health Department. Dr. Tayback headed a task force trying to increase enrollment in the federal free school lunch program and asked me, as a student-and this is the greatness of Hopkins-if I would be a working member. It gave me the opportunity to marry the clinical issues and the public health perspective.

The real work.

The school lunch program was a good way to assure appropriate nutrition and maximize the educational experience for disadvantaged children, but the negative impact on cognition had already taken place. The real work had to be directed at pregnancy and the early years of life.

To pursue that goal, the school lunch committee led to creating the permanent Maryland Food Committee [now the Maryland Food Bank]. Along with the committee, my colleagues and I tried to think through how to develop a prescriptive approach to early infant feeding and pregnancy. We started to provide iron-fortified formula to newborns at the newborn clinic in Cherry Hill, a poor neighborhood, principally African American. I should say that it wasn't until the 1980s that WIC began to promote breastfeeding.

It was really a mom-and-pop operation, I was doing almost all the work. We started collecting data on heights, weights and blood characteristics and noted a very high percentage of undergrown children, below the third percentile. Of course, a high percentage of low birth weights. The early data on the benefits of supplementing maternal and infant diets gave us courage to try to expand to a larger population.

Expansion.

We received a grant from the federal Community Services Administration to launch a statewide voucher program enabling Maryland mothers to purchase formula and nutritious food. My research confirmed that providing fortified formula to infants in low-income families reduced their risk of iron deficiency and undernutrition.

I wanted to demonstrate that the problems we were dealing with at Hopkins weren't specific to Baltimore City, that malnutrition existed anywhere poverty existed. When we submitted the grant, we coined "IFIF" as the acronym for Iron-Fortified Infant Formula Program. Our internal conversation was, "If we get the money, if we can convince the health officers," so everything was if-if, and it seemed like an appropriate acronym.

Resistance.

We had considerable resistance from many of the rural counties, where health officers had been disappointed by previous federal programs that came and went. The food vouchers were unfamiliar and untested, and no one knew if the merchants would accept them. Many of the people who most needed the program lived on the Eastern Shore [the poorest, most rural section of Maryland], where resistance from health officers was strongest. Fortunately, as a Hopkins pediatric resident I had traveled throughout the state and down to the Eastern Shore. The health officers finally accepted the IFIF program when I agreed to continue to cover their pediatric clinics once a month.

Going national.

CSA liked the IFIF program very much, and they began to spread the word on a national level, that Maryland and Baltimore and Paige and the Maryland Food Committee were the go-to people for nutrition intervention in the community, and that, obviously, they had funded us. It suddenly became bidirectional: Our appeal and our funding unleashed interest on the part of the feds, such as the Food and Nutrition Service in the USDA.

WIC has emerged as an important national program. The School and I can justly revel in its success-we didn't build it alone, but we were important architects for the program.

Long-term impact.

WIC has been very successful in lowering the incidence of low birthweight and pre-term birth, which in turn effectively reduces infant mortality and developmental disabilities. Studies by the CDC found that WIC preschoolers show improved weight gain and overall health, as well as a sharp reduction in anemia. At the same time, WIC has been extraordinarily cost-effective. Even reducing one or two nights in the neonatal intensive care unit or an extra day of a woman's hospital stay will more than compensate for the cost of WIC benefits.

Comments

  • Tony Fairhead

    United States 03/12/2014 12:53:44 PM

    Childhood Food Solutions (CFS) has developed a Pre-WIC program. CFS provides nutrition throughout pregnancies and before conception by supplying shelf-stable complex carbohydrates to a low-income zip code. We started our program in 2008 because of concern for food-insecure children and began distributing sacks of groceries to them on days they do not receive school meals, including summer break. Children share their food so we provide food for all family members.

    Our zip code is experiencing about 25 fewer premature births annually (a 30% reduction) since receiving its “food safety net.” Your finding was that: “WIC has been very successful in lowering the incidence of low birthweight and pre-term birth.” In our zip code about 30% of pregnant mothers do not receive WIC benefits until their second trimester. Our shelf-stable “food safety net” frees up the family food budget for fresh foods.

    We would appreciate the assistance of Johns Hopkins Bloomberg School of Public Health in designing and funding a Demonstration Project for four local low-income zip codes. The cost will be $500,000 but premature births are currently running at 175 per year (a rate of 19% of all births) for these zip codes, so there is much to be gained. Thank you! tony@childhoodfoodsolutions.org

  • Tony Fairhead

    Cincinnati 04/01/2014 09:58:49 AM

    I am disappointed that there are no more comments about this important possibility that maternal food security might lead to better birth outcomes than maternal food insecurity. I fear that we are all looking for medical interventions instead of wondering about our nation's continuing increase in food insecurity among those choosing to become mothers.

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