Every time Dr. Diana Cutts walks into the pediatric clinic at Hennepin County Medical Center in Minneapolis, she knows there's a nearly one in three chance she'll find a family struggling with hunger.
With such research in mind -- and the knowledge that poor nutrition affects a child's physical and cognitive development -- Cutts pays close attention to whether families consistently have nutritious food at home.
When she meets parents like Shanelle Milo, a mother who recently brought in her eight-month-old daughter Saraiya for an exam, the conversation can quickly shift to food. That's what happened when Milo mentioned that she had run out of baby formula.
Milo, who lives in a shelter, told Cutts she has trouble affording enough nutritious food to feed her three children.
Cutts makes sure Milo receives benefits from the federal Women, Infants and Children program, and that she knows about food stamps.
This sort of thing happens often enough that about a year ago, Cutts launched one of the nation's first hospital-based food shelves. It allows families to walk out the door of the pediatric clinic with more than just prescriptions and doctors' orders. They also leave with bags of food, as Milo did after her appointment.
She had sometimes been giving patients food before that, said Cutts, but is now formally certified as a food shelf and works with Second Harvest Heartland food bank.
Sometimes doctors tailor the food to a family's medical needs.
Children of families that struggle with hunger are at greater risk for developmental delays in things like language and coordination.
The only other such program in the country is at Boston Medical Center, which also serves a low-income population.
Cutts, a leading researcher on child hunger, is part of Children's HealthWatch, a national group that studies young children. The group's research gives her reason to worry about kids like Saraiya.
According to a study Cutts co-authored for the journal Pediatrics, children of families that struggle with hunger are at greater risk for developmental delays -- delays in things like language and coordination.
"In these very young children, when they're experiencing the most rapid rate of brain growth, they may be particularly vulnerable to having insufficient nutrition," Cutts said.
Although a variety of factors may affect a child's brain development, nutrition plays a key role.
"In the first three years, an enormous amount of stuff is happening," said Dr. Michael Georgieff, director of the Center for Neurobehavioral Development at the University of Minnesota.
Georgieff, who studies the effect of nutrition on brain development, said poor nutrition is partly to blame for less than optimal brain development in children. But stress and poverty also are factors, and in some cases can trump nutrition, he said.
That's because in stressful situations, the body may not properly absorb nutrients.
Still, it's clear that children who don't receive proper nutrition are at risk because a child's brain needs plenty of micronutrients, he said. Iron deficiency is a common problem.
Humans need iron to make adenosine triphosphate -- the energy all cells live on. For a child's brain to structurally develop, neurons in the brain need that energy.
Georgieff describes brain development this way: "You're going to extend, you're going to meet your neighbor neuron. You're going to make a synapse. You're going to fire really excitedly to get your neighboring neuron to work. You're going to extend to the frontal lobe and say 'hi' to them."
But the brains of children who lack iron may not do all that work.
"Are you really going to do that, when you feel kind of browned out?" Georgieff asked. "So you say, 'Well, I'll make some of those connections, but I'm too tired to make all of those connections.'"
Without enough iron, the brain is less complex, less connected, he said. A person who lacks iron may develop memory problems or have slower brain functions, depending on when they lack the iron.
Cutts treats children who don't receive enough nutrients, but that's only part of the problem. She also sees children who suffer from stress and the effects of poverty, and she sees how all these factors become tangled together.
One thing she can do something about is the family's access to nutritious food.
"This is a factor we can name, and we know how to take care of," Cutts said. "And we really do have the capacity to."
For now, she's trying to expand the food shelf and develop a way for doctors at the hospital to write prescriptions for food.
Editor's note: A previous version of the story incorrectly stated that the food shelf program at HCMC opened recently. It has been in operation for a year. The current version is correct.