#69: Household Food Insecurity – Quantity, Quality, and Human Rights

November 2, 2022 | By Sam Masur

Summary

Have you ever been in a clinic and thought a patient may be struggling with food access but didn’t know what to ask? Do you wonder what food-based interventions have the strongest evidence behind them for reducing food insecurity and improving health? Or maybe you want to start your own hospital or clinic QI project related to food. Join us with all-star physician and food policy researcher, Hilary Seligman, MD as she walks us through definitions, philosophies, consequences, and interventions related to food and nutrition security!

Credits

• Producer, Writer, and Infographic: Edward Corty, MD MPH
• Executive Producer: Max Cruz, MD
• Showrunner: Sam Masur, MD
• Cover Art: Chris Chiu MD
• Hosts: Chris Chiu, MD
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Hilary Seligman, MD

Food Insecurity Pearls

1. The Hunger Vital Signs screener has a 97% sensitivity and 86% specificity for food insecurity.
2. Food insecurity among children is associated with frequent infections, iron deficiency anemia, headache, abdominal pain, depression, anxiety, tooth decay, and poor overall health, among other conditions.
3. The Supplemental Nutrition Assistance Program (SNAP) is the most effective  anti-poverty program in the United States, but it is only available to documented citizens.
4. The Food Research and Action Center (FRAC) created a toolkit with the AAP to help pediatricians screen and intervene on food insecurity.

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Household Food Insecurity Notes

Definitions

• Food insecurity: limited or uncertain access by all people at all times to enough food for an active, healthy life. (Coleman Jensen et al)
• Low food security: sufficient quantity, but budget is so low that they need to sacrifice the quality of food
• Very low food security: both quantity and quality of food is decreased due to low food budget.
• Nutrition security: focuses on having enough nutrition, not just enough calories.

Epidemiology

• 1 in 10 households have been food insecure over the past year (families tend to cycle in and out of food security).
• Households with children, single parents, lower income, Black, Latino, and indigenous populations have significantly increased rates of food insecurity.

In the clinic

• We should screen for FI when workflows are available in the clinic to intervene (Expert opinion).
• The AAP recommends screening for FI at health maintenance visits or sooner if indicated. (AAP)
• Sometimes the focus is too much on screening and less on ensuring everyone who is eligible is signed up for SNAP and WIC (Expert opinion, more below).
• Hunger Vital Signs (HVS) (Hager et al): 

• Positive HVS is anything other than “never true” for both.
• HVS has a 97% sensitivity and 86% specificity for FI (Gattu et al.) 

• Providers do not have to be the one screening, but should follow up on positive screens. 
• Use an introduction like, “I ask all of my families about access to food and we have many community resources if needed” before screening to normalize the idea that they may need some help with food insecurity and that’s okay.

Health Consequences of FI

• We must acknowledge that as a society we have chosen a social safety net system that allows people to go hungry (Barnidge et al).
• Food insecurity causes poor health, but poor health also can cause food insecurity. (E.g., taking a week off work for illness reduces food budget).
• Patients can be both food insecure and obese due to high caloric density of low-cost foods. This is where nutrition security becomes vital.
• In one study, among people with insulin dependent diabetes in low-income households, risk for hypoglycemia admission to the hospital increased by 27% in the last week of the month compared with the first  (Seligman et al).
• Children: frequent infections, iron deficiency anemia, headache, abdominal pain, depression, anxiety, tooth decay, poor overall health (Gunderson et al).
• Adolescents: Unhealthy strategies like shoplifting, sexual relationships to obtain food (Mmari et al).
• Adults: mental health conditions among mothers, iron deficiency anemia, type 2 diabetes, hypertension (Gunderson et al).

Interventions

• These interventions aim to improve food insecurity and dietary intake, our main outcomes of interest. If we wait for evidence to show impact on long term health, we will be waiting for decades of data (Expert opinion).

Federal assistance programs

The most impactful interventions for FI that we have. These are the first line of defense.

• SNAP: The most effective anti-poverty program in the US. Available to anyone who is a documented citizen who meets certain income criteria unless they are an able-bodied adult who are not caretakers.
• WIC: Benefits for pregnant and postpartum mothers and children up to age 5. Available to anyone living in the US.
• School lunch: Must meet federal nutrition standards. The average school lunch served from the cafeteria is healthier than a lunch packed from home. 

Community based organizations

• Food pantries: distribution sites for food banks. Can be found in mobile vans, churches, schools, and more!

• Farmer’s markets

• Home-delivered meals: strong evidence that home delivered meals reduce food insecurity and reduce hospitalization among older people (Berkowitz et al).

On-site clinical programs

Becoming more and more integrated with community based organizations (e.g. vouchers to use at a community food pantry).

• Onsite food provisions

• Fruit and vegetable voucher/prescription programs: one study in Flint, MI showed that caregivers preferred vouchers to provisions so that they could pick their own foods (Saxe-Custack et al).

Plugs

• Food Research and Action Center (FRAC) is a group that presents up to date information on research, advocacy, and clinical tools related to food insecurity across the lifespan. 
• They created a Toolkit with the AAP to help pediatricians screen and intervene on food insecurity. 

Life Hack

Hillary’s life hack: teaching her children how to cook

Goal

Listeners will understand the physical and mental health consequences of household food insecurity in the United States and identify strategies to combat this condition.

Learning objectives

After listening to this episode listeners will…  

1. Recall the prevalence of household food insecurity in the United States and list the populations most at risk. 
2. Describe an approach to addressing food insecurity in a clinical setting. 
3. Explain a potential mechanism of chronic disease related to food insecurity.
4. Recall at least three pediatric health conditions associated with food insecurity.
5. List the three main categories of interventions to address household food insecurity.

Disclosures

Dr Seligman reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Corty EW, Seligman H, Cruz M, Masur S, Chiu C, Berk J. “#69: Household Food Insecurity – Quantity, Quality, and Human Rights”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ November 2, 2022.