Evaluating Nutrition Programs for Health and Empowerment: Intergenerational Evidence from the U.S. and Madagascar

Abstract

Child malnutrition remains a major global health challenge, with both stunting and obesity contributing to impaired development, increased disease risk, and premature mortality. Globally, 149 million children under 5 are stunted and nearly 390 million children ages 5-19 are obese. Prevalence varies widely across regions, highlighting the influence of broader structural and economic conditions on nutritional outcomes. Food insecurity is a major drive of child malnutrition, as households with inconsistent access to nutritious food are more likely to experience both undernutrition and obesity. Given food insecurity’s disproportionate burden in low-income households and its potential to persist across generations, child malnutrition and food insecurity can be understood within a poverty traps framework, where families and communities are stuck in self-reinforcing cycles of economic hardship and poor health. Existing interventions that target individuals or households alone have demonstrated limited impact, suggesting that to address these issues requires broader societal and structural interventions and, critically, greater understanding of their long-term and intergenerational effects. In Chapter 1, I assessed the association between SNAP participation in childhood of a parent and the SNAP participation in childhood of their child in the Panel Study of Income Dynamics. I demonstrate an intergenerational continuity of SNAP participation that is likely driven by the structural and economic conditions that perpetuate food insecurity and poverty. These results highlight the long-term impact that cuts to programs like SNAP will have on keeping vulnerable families in poverty. In Chapter 2, I built upon the results from Chapter 1 by examining the association between SNAP participation exposure patterns in childhood of a parent and the primary caregiver-rated health and food insecurity of their child. I identified four distinct SNAP participation exposure patterns in childhood and found that chronic SNAP exposure increased the risk of food insecurity in the next generation. These results indicate that extensive participation in SNAP may be a marker for persistent economic hardship, with generational poverty continuing to have adverse effects on families over time. In Chapter 3, I examined the potential mediation of a community-led total nutrition program’s effects on child diet and growth by indicators of women’s empowerment in Madagascar. I found that women’s empowerment is domain-specific, with different aspects having differing effects. Overall, there are numerous mechanistic pathways by which a community-level intervention may increase child diet and growth, with women’s empowerment playing only a small possible role. In conclusion, this dissertation demonstrates that child malnutrition and food insecurity are not isolated or short-term conditions, but instead outcomes shaped by persistent structural inequities that can extend across generations. While programs such as SNAP and CLTN can improve child health and well-being, they exist within broader socioeconomic environments that keep vulnerable families within detrimental cycles of poverty. Understanding how these structural conditions operate and how interventions can disrupt or reinforce long-term cycles is critical for developing future policies and programs capable of creating sustained improvements in child nutrition and health.