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Food Insecurity and What Clinicians Can Do About It

Learning Objectives
1. Describe the prevalence of food insecurity in the U.S., including discussion of populations at special risk
2. Review the use of a validated rapid assessment tool for identification of individuals with food insecurity
3. Discuss options for referral of patients identified with food insecurity
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About the Gaples Institute
The Gaples Institute is an educational nonprofit that develops high-yield nutrition education, enabling physicians to meaningfully incorporate nutritional interventions for optimal patient (and self) care. Learn more.

Audio Transcript

Jeanette Brooks: Hello, and welcome to Medicine with a Fork, produced by the nonprofit Gaples Institute. We are an educational nonprofit whose mission is to advance the role of nutrition and lifestyle in medicine—and this podcast is one of the ways we're doing that.

I'm Jeanette Brooks, the Director of E-Learning Experience for the Gaples Institute, and with me today is our Executive Director, Dr Stephen Devries. He's also a preventive cardiologist with more than three decades in academic medicine. Steve, thanks for joining me.

Dr Stephen Devries: Great to be with you.

Brooks: So in health care, we understandably direct a lot of attention to a patient's physical being: their symptoms or the health conditions that we are trying to treat or prevent. But today, Steve, I want to ask you about a concern that is definitely a driver of a patient's health status, even though it has nothing to do with their symptoms or typical markers, like their lipid panel or their genetics.

And that challenge is food insecurity. I know that this is an area that you've examined quite a bit recently, so to kind of open this up, I was hoping you could help bring things into focus and tell us: What does food insecurity mean; how would you define it?

Devries: Food insecurity describes the lack or uncertainty in a household about having adequate food to support the health of all the family members.

Brooks: Okay. So, to kind of bring it under the lens of a clinical encounter, what do you see as the physician's role here, as far as diagnosing or addressing food insecurity?

Devries: Physicians can play a really important role. First of all, they can help to identify patients who are food insecure, as well as to help them to get the resources they need to improve their access to food.

Brooks: Okay. Can you tell us a little bit about what you've seen as the prevalence of this problem? How big of an issue are we looking at here?

Devries: It's a really major and scary problem, food insecurity. We know that one out of every nine Americans—or more—are food insecure. One out of every nine!

And there are certain groups for whom food insecurity is an even a bigger problem. 21% of people living with Black heads of households are food insecure. 28% of households headed by single women with children are food insecure. And, equally shocking, or maybe more so, 19% of college students are food insecure.

So this is an issue across the board that is major, and food insecurity within certain groups is really completely out of control.

Brooks: Yeah, it really sounds like it, those numbers are very remarkable—much higher than I would have imagined. And I know at least in my town where I live, it seems like the pandemic has really added another whole layer of urgency and complexity to this problem. Have you seen that too, that COVID seems to have really changed the landscape of food insecurity?

Devries: Absolutely. And it's not hard to imagine how that came to be. As people lose their jobs and they are working less, their incomes drop and their access to food in many cases has dropped. People who work in food banks or know people who do, know that this is a huge issue. The line in food banks has never been longer than it is now, especially for families with children involved. We know that food insecurity in those groups are especially alarming. So yes, COVID has been a magnifier that took a really bad problem before COVID and has made it much, much worse.

Brooks: And it seems like we haven't quite seen the peak yet of it either. It seems like it's still continuing to rise for the foreseeable future. Definitely something that we need to be prepared to address.

So let's talk a little bit about the clinical aspects of this. I know that malnutrition and hunger create obvious concerns, but what are you seeing as far as specific health outcomes? Are there medical issues that seem to be linked specifically to food insecurity?

Devries: You're quite right. Obviously food insecurity leads to hunger, which is a terrible problem in and of itself, but many people don't recognize that in addition to that horror, there are medical issues, many of them linked to food insecurity.

Let's start with children. In children, a whole host of conditions are linked to food insecurity, and they include low birth weight as well as many developmental delays. And in adults, it's a long list of conditions linked to food insecurity. They include chronic kidney disease, coronary artery disease, congestive heart failure, and type 2 diabetes. The risk of type 2 diabetes goes up more than twofold among people who have food insecurity compared to those who don't. So this is a really compelling medical issue.

Brooks: Definitely multifaceted, it sounds like. And with the prevalence that you mentioned, those percentages are so alarming. What I'm hearing from you, then, is that even if a physician feels like, “my patients seem fine, they don't seem like they're struggling,” or if you practice in an affluent community, it sounds like it's still highly likely that a significant number of your patients are facing this problem.

So with that in mind, how hard is it to surface this? Can we tell physicians, “this is what food insecurity looks like when a patient walks in the door”? Are there visual clues that a physician can rely on?

Devries: No, really there are not reliable visual cues to help you identify patients who are food insecure, because people who appear to be well dressed and have all of the outward appearances of someone who you wouldn't suspect as having food insecurity issues or financial problems—they can absolutely be at risk.

So you cannot tell by appearance. It may be that people have recently lost their job and their financial situation has changed, so they can present with very stylish-looking clothes and appearances—and yet the situation at home can be quite dire.

Brooks: Definitely an issue where stereotypes are not helpful. So what is the best way, Steve, that a clinician can keep an eye out for food insecurity? Is there a way to screen for this?

Devries: Fortunately, yes, there is a really efficient way to screen for food insecurity. It involves a validated two-question screening tool, and fortunately, it's really quick to do—it takes no more than a minute.

So it consists of two questions and they are the following. Number one: within the past 12 months, were you worried that the food you had would run out before you could get money to buy more? And the second one is: Within the past 12 months, was there ever a time when the food you bought just didn't last and you didn't have money to get more?

If the answer to either of those questions is “often that's the case” or “sometimes that's the case,” to either question, then you need to consider that patient as being food insecure.

Brooks: I like how there is a time element to it too, that it's specifically within the last 12 months, because obviously many people's situations are rapidly changing during this time in history.

Say that when you do the screening with those two questions, what happens if the patient does answer affirmatively to one of them or both of them? What then? What's the best way for the clinician to help?

Devries: Well, first of all, just to acknowledge that if the patient does answer affirmatively to one of those questions, you've done something really important. You've started them perhaps on the road to a much better situation.

So what you can do, number one, is to make referrals to appropriate resources, including social workers. Social workers can often direct people and connect them to governmental resources like SNAP and other food programs that could be enormously helpful to patients.

Second, you yourself might direct them to community resources that you're aware of, including local food banks and places that offer food services. Some clinics have lists of those services available that they can give to patients. Identifying patients that the clinician can do, and as an access point to individuals who may be in need, is an enormously empowering tool that clinicians should really think about, especially at this time.

Brooks: Great reminder to develop those referral relationships and the resources in your community, so that you're ready when you discover that a patient could benefit. A lot of times, I'm sure that referral might end up being the lifeline that that person desperately needs.

One more question that came to mind when you were describing this screening process: What about concerns related to dignity and privacy? I imagine this topic might be a sensitive one for some patients, if they're maybe embarrassed or they feel some discomfort to talk about their needs. Do you have any recommendations about how to help them feel okay about disclosing food security challenges?

Devries: Well, it's a great question, and it's absolutely right—this is a loaded topic. Any topic that involves finances and a situation that's uncomfortable for people to describe.

So the way I like to approach the topic is to kind of talk to patients with something like this: to start out by saying that “food is such an important aspect of health, I like to ask all my patients about how hard it might be for them to have food in the house. And so I'd like to ask a couple of questions…” Something like that, to make it seem like it's just a routine part of what you do for everyone—not to necessarily give the patient themselves an indication that you've identified something that may have triggered you asking that question.

And in fact because it is, as we discussed, so difficult to really predict which patients do have food insecurity and which don't, it is a question that all clinicians should ask all of their patients.

Brooks: Those are great suggestions, Steve, thank you so much for all of this. It's really a timely topic for anyone in patient care and really great to know that there are tools and strategies available.

Devries: So good to discuss this topic that couldn't be more important, especially now.

Brooks: For clinicians who would like more resources, not only about food insecurity, but also on a whole spectrum of clinical nutrition issues, we invite you to check out NutritionForDocs.org. That's where you will find our nonprofit's interactive nutrition science course for clinicians. It's online, it's self-paced, and you'll earn four hours of continuing medical education while you're at it. And AMA members do receive a discount.

We also invite you to follow the nonprofit Gaples Institute on social media. I'm Jeanette Brooks with Dr Stephen Devries, and we look forward to seeing you next time on Medicine With a Fork.

Audio Information

©Copyright 2021 - Gaples Institute

Disclosure Statement: Dr. Devries is the salaried executive director and Jeanette Brooks is the salaried director of e-learning for the Gaples Institute, an educational nonprofit that offers accredited continuing medical education courses for sale to health professionals. Courses are developed entirely through philanthropy to the Gaples Institute, a nonprofit that does not seek or receive corporate support. Neither Dr. Devries nor Jeanette Brooks receive royalties or personal consideration of any kind from the sale of these courses.

Financial Support Disclosure Statement: This podcast was developed with no corporate support.

References:
1.
Coleman-Jensen  A, Rabbitt  M, Gregory  C, Singh  A.  Household Food Security in the United States in 2018.  In:  U.S. Department of Agriculture ARS, 2019.Google Scholar
2.
Hager  ER, Quigg  AM, Black  MM,  et al.  Development and validity of a 2-item screen to identify families at risk for food insecurity.  Pediatrics. 2010;126(1):e26–32.Google Scholar
3.
Tait  CA, L'Abbe  MR, Smith  PM, Rosella  LC.  The association between food insecurity and incident type 2 diabetes in Canada: A population-based cohort study.  PLoS One. 2018;13(5):e0195962.Google Scholar
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