November 1996

Grant Results


This unsolicited project was designed to bridge the significant gap in services that combat homelessness and those that fight against malnutrition in women and children.

From 1991 to 1995, staff at Boston City Hospital addressed this dichotomy in services through nutrition education, nutrition surveillance and public policy change.

Key Results

  • Project staff screened more than 600 homeless children age 6 and under for malnourishment, and evaluated 216 pregnant homeless women at nutritional risk.
  • Project staff established a nutrition education curriculum and presented almost 200 nutrition education sessions in homeless shelters and hotels.
  • Staff shared the curriculum and findings through national dissemination.
  • The project also developed models of primary and secondary prevention of nutritional morbidity among homeless women and children. Piloted in the Boston area, these models can now be used nationally.

Key Findings

  • Combating the problem of homelessness and hunger will require a deliberate, focused short-and-long-term approach.
  • It is possible to organize a system to address both homelessness and hunger.

The Robert Wood Johnson Foundation (RWJF) supported this project with a grant of $394,014 from September 1991 to January 1995.

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Widespread consensus points to malnutrition as a major problem for homeless women and children, yet little documented evidence of this problem exists. There has been almost no effort to design and test therapeutic interventions, or to conduct nutrition education programs for clinicians and other professionals working with the homeless. Reports are that at least 100,000 children are homeless on any given night and that rates of pregnancy and low birthweight due to multiple factors, including poor nutrition are high among homeless women.

A review of the literature by the project director, who is Director of the Growth and Development Program at Boston City Hospital, uncovered anecdotal evidence suggesting that many homeless children suffer from nutrition-related problems including infections, diarrhea, growth failure, dehydration, and developmental impairment.

An informal survey of health care to the homeless across the country revealed an absence of concerted efforts to deal with serious nutritional problems—inadequate food supplies, lack of refrigeration and cooking facilities, and poor understanding of nutrition by both health care providers and the homeless. Pregnant homeless women at nutritional risk should be identified and referred for appropriate care, staff and residents of shelters need to be educated in basic nutrition and in handling food in a shelter setting, and families in hotels must know how to store and prepare food in their inadequate surroundings.

The project focused on these problems and on the absence of programmatic or public policy strategies in this area.

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The unsolicited project bridged gaps in nutritional services for homeless women and children. The project worked closely with Boston Health Care for the Homeless Program (BHCHP), which provides comprehensive services to the homeless; Project Bread; and the Failure to Thrive Program at Boston City Hospital, which evaluates and treats malnourished children with moderate to severe growth delay using a multidisciplinary team of health professionals. Help and support was received in the form of food donations from churches, synagogues, and community groups.

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The project's nutrition assessment program screened both homeless children and pregnant women believed to be at nutritional risk. Its nutrition education program conducted almost 200 nutrition education sessions, and developed a curriculum and videotape that can be disseminated to nutrition and shelter programs nationwide.

The project also bridged gaps in services with its models of nutritional education and surveillance. It collaborated successfully with other agencies, such as the Western Massachusetts Food Bank, the Massachusetts Dietetic Association, the Massachusetts Public Health Association, the American Red Cross, and the Massachusetts State Department of Health. Throughout, the project advocated the nutritional needs of homeless families to in city, state and national forums.

Nutrition assessments made. The project assessed the special nutrition education needs of homeless families living in hotels. Survey results helped shape the content of educational programs. Among the findings are that homeless families living in motels:

  • Cook in microwave ovens shared by multiple families, store food in tiny refrigerators, and usually have no food preparation and dishwashing facilities.
  • Shop most often in convenience stores where prices are high.
  • Eat in restaurants less often and use convenience stores less frequently if bus service is provided to a supermarket, compared to those without transportation.
  • 52 percent reported running out of food during the current month.
  • 18 percent have no cooking utensils in their room; 13 percent have no eating utensils.
  • 46 percent are not participating in the federally sponsored Women, Infants and Children (WIC) program.

Child measurements conducted. BHCHP health care personnel were equipped with portable scales and measuring boards, and trained to take anthropometric measurements of homeless children age 6 and under. The project screened 601 children and found that:

  • 7 percent were inordinately short for their age, indicating chronic malnourishment.
  • 6 percent were acutely underweight for their height.
  • 12 percent were overweight for their height.

Pregnant women screened. The project screened 216 pregnant homeless women, from neighborhoods with the highest infant mortality rate in the city. Among their findings:

  • Of 39 women in the first trimester, 33 percent had lost weight compared to their pre-pregnancy weight.
  • Of 155 women in the second and third trimester, 32 percent gained less than the minimum recommended weight for their gestational week.

As a result of this screening, BHCHP implemented an infant growth monitoring system.

Focus groups conducted. The project conducted focus groups and a survey to determine the most important nutrition and food handling issues in shelters and hotels. These issues included how to use a microwave oven, how to prepare "no cook" meals, and how to deal with the feeding issues of children. The project also established working relationships with local family shelters and with heterogeneous groups within the homeless population in Boston.

Nutrition education video produced. A video, "Homeless, Not Hungry," was produced to help homeless families in hotels better manage their nutrition needs. The video features actual homeless women and their children, and addresses topics raised by the focus groups as well as other issues—access to food programs, shopping economically, and understanding food sanitation.

Curriculum on nutrition developed. A comprehensive national curriculum was presented in a non-traditional manner (role play, cooking demonstrations, skits, puppet shows) meant to appeal to audiences, and change food and nutrition practices in homeless shelters and hotels.

Nutrition sessions held. The project conducted 180 nutrition sessions in 17 shelters and transitional housing programs and three hotels. The subject matter varied to include nutrition and HIV, sanitation and food safety, appropriate feeding of toddlers, and economical food buying.

Models created. The project consulted for a national anti-hunger organization, Share Our Strength, which has developed a program, Operation Front Line, modeled after the project's nutrition education program. Operation Front Line provides professional chefs as volunteer instructors for nutrition and food preparation classes for low-income families. It also developed a model nutrition surveillance system currently in use by BHCHP. This model systematically identifies pregnant homeless women at risk and refers them for care.

Public policy affected. Through the project's efforts, homelessness was made a criterion of nutritional risk for WIC certification in Massachusetts. The project also trained WIC program staff to better assess the needs of families living in hotels. Based on nutrition surveillance data and supported by RWJF funds in 1991–92 and technical assistance from project staff, BHCHP obtained Boston Healthy Start Initiative funds for a full-time and part-time nutritionist for their maternal child health team.


  • Combating the problem of homelessness and hunger will require a deliberate, focused short-and-long-term approach.
  • It is possible to:
    • Organize a system to address both homelessness and hunger.
    • Combat nutritional risk in homeless children and pregnant women.
    • Accumulate key data about this high-risk population.
    • And to apply this data to advocate for this vulnerable population.


Abstracts were presented to the American Public Health Association and the American Pediatric Society/The Society for Pediatric Research. Project staff presented workshops on nutritional and homeless pregnant women and children at RWJF; US Department of Housing and Urban Development, Homeless Families Program, Second Annual Meeting; and at the Ambulatory Pediatric Association. Project staff presented the results of their work for the Children's Defense Fund and at a Capitol Hill lunch sponsored by the Center on Hunger, Poverty, and Nutrition Policy.

The project also produced educational pamphlets: "Grow Diet;" "Dieta Para Crecer;" "Homeless Not Hungry;" "Eating Better, Eating Cheaper;" and "Minute Meals: Microwave Safety and Cooking Tips." Thousands of these pamphlets were distributed to residents in homeless shelters and at nutrition classes and conferences. A nutrition curriculum for nutritionists and other health care professionals was produced and 130 copies of it are being disseminated.

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  1. Outside supports and collaborations are often essential to community projects. Food donations from churches, synagogues, and community groups helped offset the overwhelming need for food by homeless families.

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With RWJF encouragement, the grantee submitted proposals to other national foundations for support to monitor the nutritional impact of cuts in child nutrition, income maintenance, and housing and fuel assistance programs. However, there has been no further funding provided. The project has taken other steps to extend its work beyond RWJF funding:

  • Enabled the startup of Operation Front Line nutrition classes in shelters, sponsored by Share Our Strength.
  • Helped to implement cooperative food buying for shelters through a consortium arrangement, resulting in lower food costs and wider nutritional variety.
  • Continues to educate homeless residents about entitlement programs, soup kitchens, and best food buys.

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Program to Treat and Reduce Malnutrition Among Homeless Children


Trustees of Health and Hospitals of the City of Boston (Boston City Hospital) (Boston,  MA)

  • Amount: $ 394,014
    Dates: September 1991 to January 1995
    ID#:  018177


Deborah A. Frank, M.D.
(617) 534-5251

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Report prepared by: Robert Mahon
Reviewed by: Molly McKaughan
Program Officer: Stephen A. Somers

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