By R. Susan Daily, M.D., Eunice Y. Yuen M.D., Ph.D., and the Child Committee of the Group for the Advancement of Psychiatry

Lily is a Caucasian 17-year-old girl coming to a family medicine clinic with fatigue and shortness of breath when walking. She has been depressed for more thanr two years, suffers anxiety, and has panic attacks. She reports muscle aches/pains, headaches, rashes, a sore mouth and bleeding gums when brushing her teeth, irritability, thinning hair, broken sleep, acid reflux, and chronic constipation.

High poverty rates, rising food prices, and food insecurity have plagued the U.S. for decades. A 2023 USDA Food Security Report found that food insecurity exists in about 18% of homes with children. Food insecurity affects families in which parents have less than a high school education as well as those with a head of household having college education (at least 20% of food insecure homes).

In 2020, 19.6% of homes were food-insecure, which translates to 47.4 million food-insecure people, including 13.8 million children. Families of color had more than double the rates of White non-Latinx households, while those living in the southern U.S. suffered higher rates than those in any other region. In addition, access to food is limited bythe existence of food deserts, lack of transportation, and cost of items overall.

A poverty diet is one based on very limited funds and/or access to nutritional foods. The diet is usually high in sugar, fat, and salt. There are very few fresh fruits and vegetables. Proteins are provided by the cheapest and fattiest cuts of meat.

Family Food Poverty

Lily’s family consists of her mother (43 years old), stepfather (42), Lily (17), Andrew (15), Steven (11), and Miriam (9). Her stepfather is a construction worker, and her mother is a nurse’s aide. Both have long work hours and take on extra shifts. Lily’s biological father helps when he can, but he does not always have employment.

Along with their parents, Lily and her brother also work, for a total household income of about $55,000/ year. This is $12,000 above the poverty level in their state for a family of six, so they do not qualify for Supplement Nutritional Assistance Program (SNAP) or other social support programs. The children can get free breakfast and lunch at school.

Lily and Andrew do most of the cooking and childcare, including helping with homework. Common meals in their home include pasta, rice, beans, tortillas, potatoes, cheese, hot dogs, and pizzas. An occasional treat is fresh fruit.

Lily’s medical workup revealed anemia and multiple nutrient deficiencies (vitamins B6, B12 C, and D, and minerals iron, selenium, and zinc). The missing nutrients are found in fruits, vegetables, milk products, whole grains, and meats.

The Toll of Dietary Deficiencies

Dietary deficiencies can cause an array of symptoms.

• Vitamin B12 deficiency – fatigue, weakness, depression, irritability, and poor sleep quality.
• Vitamin B6 deficiency – rash, anxiety, depression, and fatigue.
• Vitamin D deficiency – increased risks of bone fractures, bone pain, muscle aches and cramps, moodiness, fatigue, and poor sleep quality.
• Vitamin C deficiency – fatigue, weakness, muscle aches, and, in severe cases, scurvy.
• Zinc deficiency – sores at the corner of the mouth, hair loss, and skin rashes.
• Iron deficiency – anemia, fatigue, broken sleep, headaches, depression, and feeling out of breath.
• Selenium deficiency – fatigue, muscle weakness, and hair loss.

Lily’s constipation was due to a lack of fiber in her diet, with fiber often found in fruits, whole grains, and vegetables. Her acid reflux was worsened due to drinking caffeinated carbonated beverages at work. Her deficiencies corrected, she was advised to avoid acidic and caffeinated beverages. A serious challenge was to improve the diet for Lily and her family.

Lily is a typical child whose family is working hard to keep their lives stable. After paying rent, utilities, insurance, and transportation costs, there is little left for groceries. Relieving the anxiety of day-to-day struggles at any level will be helpful to families’ mental and physical health.

Community, Not Just One Family

The core of human health is appropriate nutrition and adequate sleep. When these are inadequate, the overall level of function declines. The body and the mind start to break down, with increasing risks of depression and anxiety symptoms. Nutritional deficiency is also directly linked to illnesses such as anemia and scurvy, which are preventable.

If a portion of the population is malnourished, the community at large suffers as well from decreased contributions to society, increased illness burden, and decreased work capacity. This is a core economic issue as well as a health issue. A well-nourished and healthy populace is a necessary foundation for building a productive society.

Recommendations for Healthcare Professionals

• Perform diet and nutrition reviews with children and their families, not just initially but also periodically.
• Assess nutritional and necessity access.
• Do not assume reliable nutrition based on the level of education or neighborhood. Economic hardships can hit all levels of society.
• Keep a list of local food banks with hours and qualifiers for service areas.
• Have a list of local resources for clothing, shoes, and school supplies, as money spent on these takes away from the food budget.
• Know the referral process for the USDA Supplemental Nutrition Programs for Women, Infants, Children (WIC), SNAP, etc.

Resources for Families

Some existing government resources to remedy food insecurity include:

Final Thoughts

Treating vitamin deficiency in children and families living in poverty is only the tip of the iceberg and, at best, a stopgap to addressing long-term problems with food insecurity and effective nutrition. Community leaders can influence policy development and implementation to help children and families overcome poverty.

Everyone is vulnerable to experiencing poverty and deprivation, and everyone should be ready to address these devastating conditions within their communities.

R. Susan Daily, M.D., is a child psychiatrist for the Cherokee Nation in Oklahoma and volunteers her time to the local medical training programs.

Eunice Y. Yuen M.D., Ph.D., is an Assistant Professor of Psychiatry at Yale School of Medicine and Child Study Center and co-chair of the GAP Child Committee.