Editorials

Food Insecurity in the United States: Its Effect on Our Patients



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Am Fam Physician. 2004 Mar 1;69(5):1058-1064.

The term “food security” refers to the concept of people having access to enough food, including the ready availability of nutritionally adequate, safe foods for an active, healthy life and the ability to acquire these foods in socially acceptable ways.1 When individuals and families have limited access to food or if their ability to obtain food is limited or uncertain (food insecurity), they often resort to the use of emergency food supplies, or they beg, steal, or scavenge for food.1

Standardized measures of U.S. household food security status are included in the Census Bureau's Current Population Survey and other large national surveys.2,3 In 2001, 10.7 percent of U.S. households were unable to secure adequate amounts of food; and in 2002, that number rose to 11.1 percent, representing 12.1 million households and 34.9 million people, including 13.1 million children.4

For the practicing physician, a thorough history is key to uncovering and then assisting patients experiencing food insecurity. Generally, households unable to secure adequate amounts of food have limited resources, and lack access (because of limited resources, lack of transportation, living in remote areas, or limited access to food stores). To cope, these people depend on food assistance programs, substitute less expensive alternatives for nutritious foods, seek assistance from emergency feeding programs (e.g., soup kitchens and food pantries), and skip meals.5 The households that are at higher risk of being unable to secure adequate amounts of food are those whose income falls below the official poverty line; those headed by a single woman with children; those with black or Hispanic members; those with children; and those located in central cities or rural areas, or in southern and western states.4

When persons lack access to proper food, physical impairment, psychologic suffering, and sociofamilial disturbance may result.6 In fact, having adequate food is vital to achieving the U.S. Healthy People 2010 objectives.7

Among adults, poor or fair self-rated health and physical limitations, poorer functional health status, and depression were associated with the inability to secure adequate amounts of food. An increase in disordered eating patterns and a decrease in consumption of fruit, vegetable, or dairy consumption was also noted. Food insecurity has been associated with decreased caloric intake, as well as decreased intake of nutrients, including antioxidants. Paradoxically, food insecurity has been associated with a greater body mass index and obesity among women.8,9 It has been speculated that the relationship of obesity and food insecurity may be mediated by the low cost of energy-dense foods and reinforced by the pleasing taste of sugar and fat.10

Although inability to secure adequate amounts of food may not have immediate health effects, the risk of chronic disease appears to increase in patients experiencing food insecurity.8,9

TABLE 1

Food Security Factors to Consider During an Office Visit

Factors Possible resources/treatment plan considerations

Availability of resources necessary for implementing the prescribed medical care

Money for medication or food; availability of appliances (refrigerator, freezer); availability of utilities (natural or propane gas, electric, water); availability of transportation

Participation in food assistance programs

Federal programs (Food Stamps, National School Lunch, Special Supplemental Nutrition Program for Women, Infants, and Children); food pantries, soup kitchens, community gardens, and other non-Federal programs

Other means of acquiring food

Gardening, hunting for game or fish

Nutrition education to help preserve food resources and reduce food waste

Meal planning and purchasing tips; label-reading tips (meaning of manufacturers' expiration codes and other dates on packages); food safety education (e.g., safe food preservation tips)

TABLE 1   Food Security Factors to Consider During an Office Visit

View Table

TABLE 1

Food Security Factors to Consider During an Office Visit

Factors Possible resources/treatment plan considerations

Availability of resources necessary for implementing the prescribed medical care

Money for medication or food; availability of appliances (refrigerator, freezer); availability of utilities (natural or propane gas, electric, water); availability of transportation

Participation in food assistance programs

Federal programs (Food Stamps, National School Lunch, Special Supplemental Nutrition Program for Women, Infants, and Children); food pantries, soup kitchens, community gardens, and other non-Federal programs

Other means of acquiring food

Gardening, hunting for game or fish

Nutrition education to help preserve food resources and reduce food waste

Meal planning and purchasing tips; label-reading tips (meaning of manufacturers' expiration codes and other dates on packages); food safety education (e.g., safe food preservation tips)

Family physicians should be aware that their patients may have difficulty complying with prescribed treatments simply because of issues related to food insecurity. Unfortunately, patients often are faced with difficult decisions. One report prepared for America's Second Harvest11 revealed that 30 percent of emergency food clients were faced with the choice of paying either for food or for medicine or medical care. In addition, 45 percent were faced with choosing to pay for food or for utilities or heating fuel, and 36 percent had to choose between paying for food or rent or mortgage payments.11

While family physicians face time constraints when interacting with patients, to improve patient access to food, physicians should inquire about weight loss and dietary habits resulting from having limited resources. Examples of dietary habits that may result include relying on only a few kinds of low-cost foods, not eating a variety of foods or “balanced” meals, eating less or cutting meal size, skipping meals, and not eating when hungry. Several other factors also should be considered during an office visit to facilitate food security (Table 1). Knowing and understanding the culture of the community will guide additional points to consider in the office visit. Some practices involve other health professionals, including registered dietitians and social workers, who can assist in helping patients to secure adequate amounts of food.

Ultimately, referrals may be necessary to assist the patient in securing adequate food. A variety of programs are available across the United States, and others are unique to particular communities (Table 2). An understanding of the household structure will assist physicians in making appropriate referrals. For example, a physician may see a young adult male whose spouse is pregnant and whose elderly father lives with the family. Using a current list of community programs, it would be appropriate to advise the patient that his wife may be eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children, and that his father may be eligible for service from Meals on Wheels.

TABLE 2

Food Assistance Programs

Programs Program summary, referral information, and Web site addresses

Child and Adult Care Food Program

Provides nutritious meals and snacks to children and adults who receive day or after-school care away from home and to children residing in homeless shelters. Usually administered by the stateeducation agency. Refer clients directly to programs in the community.

Web address: http://www.fns.usda.gov/cnd/care

Expanded Food and Nutrition Education Program

Helps limited-income families and youth acquire knowledge, skills, attitudes, and behavior changes necessary to maintain nutritionally sound diets and enhance personal development (basic nutrition, food preparation, resource management). Refer clients to the county extension office.

Web address: http://www.reeusda.gov/f4hn/efnep/efnep.htm

Food Distribution Programs such as: Child Nutrition Commodity Support; Nutrition Services Incentive Program (formerly the Nutrition Program for the Elderly); Commodity Supplemental Food Program; Food Assistance in Disaster Situations; Food Distribution Program on Indian Reservations; the Emergency Food Assistance Program; State Processing Program; Nutrition Assistance Program for Puerto Rico, American Samoa, and the Northern Marianas; and Homeless Children Nutrition Program

Overall, these programs support the nutrition safety net through commodity distribution and other nutrition assistance to low-income families, emergency feeding programs, Indian reservations, and the elderly. Refer clients to local food banks and pantries or other agencies/organizations, including faith-based groups, where supplemental foods are distributed. Your local food bank can be accessed through America's Second Harvest.

Web addresses:

http://www.secondharvest.org

http://www.fns.usda.gov/fdd

http://www.fns.usda.gov/fns/menu/programs.htm

Food Stamp Program

Enables low-income families to buy nutritious food with coupons and Electronic Benefits Transfer cards. Food stamp recipients spend their benefits to buy eligible food in authorized retail food stores. Refer patients to the local food stamp office.

Web address: http://www.fns.usda.gov/snap

National Meals on Wheels Foundation

Dedicated to the delivery of meals to homebound senior citizens and those at congregate sites. Programs are organized by a variety of groups, including local communities, churches, charitable organizations, and concerned citizens. Refer clients directly to programs. The Area Agency on Aging may be helpful.

Web address: http://www.nationalmealsonwheels.org

National School Lunch and School Breakfast Programs

Provides nutritionally balanced, low-cost or free breakfasts and lunches to children enrolled in public and nonprofit private schools and residential child care institutions. Also provides snacks served in after-school educational and enrichment programs for children through 18 years of age. Refer patients to local schools.

Web addresses: http://www.fns.usda.gov/cnd/lunch/default.htm and http://www.fns.usda.gov/cnd/breakfast/default.htm

Senior Farmers' Market Nutrition Program

Provides low-income seniors with coupons that can be exchanged for eligible foods (fresh, nutritious, unprocessed fruits, vegetables, and fresh-cut herbs) at farmers' markets, roadside stands, and community-supported agriculture programs during the harvest season. Refer clients to local programs. The Area Agency on Aging may be helpful.

Web address: http://www.fns.usda.gov/wic/seniorFMNP/SFMNPmenu.htm

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and WIC Farmers' Market Nutrition Program

Provides supplemental foods, nutrition education and counseling, and access to health services to low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women, and to infants and children up to 5 years of age, who are found to be at nutritional risk. As part of the WIC Farmers' Market Nutrition Program, a variety of fresh, nutritious, unprepared, locally grown fruits, vegetables, and herbs may be purchased with coupons. Refer patients to the local WIC agency.

Web addresses: http://www.fns.usda.gov/wic and http://www.fns.usda.gov/wic/FMNP/FMNPfaqs.htm

Summer Food Service Program

Provides nutritious breakfasts, lunches, and snacks to ensure that children in lower-income areas continue to receive nutritious meals during long school vacations when they do not have access to school lunch or breakfast. Refer children to local summer programs. Area schools may have information about available programs.

Web address: http://www.summerfood.usda.gov

TABLE 2   Food Assistance Programs

View Table

TABLE 2

Food Assistance Programs

Programs Program summary, referral information, and Web site addresses

Child and Adult Care Food Program

Provides nutritious meals and snacks to children and adults who receive day or after-school care away from home and to children residing in homeless shelters. Usually administered by the stateeducation agency. Refer clients directly to programs in the community.

Web address: http://www.fns.usda.gov/cnd/care

Expanded Food and Nutrition Education Program

Helps limited-income families and youth acquire knowledge, skills, attitudes, and behavior changes necessary to maintain nutritionally sound diets and enhance personal development (basic nutrition, food preparation, resource management). Refer clients to the county extension office.

Web address: http://www.reeusda.gov/f4hn/efnep/efnep.htm

Food Distribution Programs such as: Child Nutrition Commodity Support; Nutrition Services Incentive Program (formerly the Nutrition Program for the Elderly); Commodity Supplemental Food Program; Food Assistance in Disaster Situations; Food Distribution Program on Indian Reservations; the Emergency Food Assistance Program; State Processing Program; Nutrition Assistance Program for Puerto Rico, American Samoa, and the Northern Marianas; and Homeless Children Nutrition Program

Overall, these programs support the nutrition safety net through commodity distribution and other nutrition assistance to low-income families, emergency feeding programs, Indian reservations, and the elderly. Refer clients to local food banks and pantries or other agencies/organizations, including faith-based groups, where supplemental foods are distributed. Your local food bank can be accessed through America's Second Harvest.

Web addresses:

http://www.secondharvest.org

http://www.fns.usda.gov/fdd

http://www.fns.usda.gov/fns/menu/programs.htm

Food Stamp Program

Enables low-income families to buy nutritious food with coupons and Electronic Benefits Transfer cards. Food stamp recipients spend their benefits to buy eligible food in authorized retail food stores. Refer patients to the local food stamp office.

Web address: http://www.fns.usda.gov/snap

National Meals on Wheels Foundation

Dedicated to the delivery of meals to homebound senior citizens and those at congregate sites. Programs are organized by a variety of groups, including local communities, churches, charitable organizations, and concerned citizens. Refer clients directly to programs. The Area Agency on Aging may be helpful.

Web address: http://www.nationalmealsonwheels.org

National School Lunch and School Breakfast Programs

Provides nutritionally balanced, low-cost or free breakfasts and lunches to children enrolled in public and nonprofit private schools and residential child care institutions. Also provides snacks served in after-school educational and enrichment programs for children through 18 years of age. Refer patients to local schools.

Web addresses: http://www.fns.usda.gov/cnd/lunch/default.htm and http://www.fns.usda.gov/cnd/breakfast/default.htm

Senior Farmers' Market Nutrition Program

Provides low-income seniors with coupons that can be exchanged for eligible foods (fresh, nutritious, unprocessed fruits, vegetables, and fresh-cut herbs) at farmers' markets, roadside stands, and community-supported agriculture programs during the harvest season. Refer clients to local programs. The Area Agency on Aging may be helpful.

Web address: http://www.fns.usda.gov/wic/seniorFMNP/SFMNPmenu.htm

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and WIC Farmers' Market Nutrition Program

Provides supplemental foods, nutrition education and counseling, and access to health services to low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women, and to infants and children up to 5 years of age, who are found to be at nutritional risk. As part of the WIC Farmers' Market Nutrition Program, a variety of fresh, nutritious, unprepared, locally grown fruits, vegetables, and herbs may be purchased with coupons. Refer patients to the local WIC agency.

Web addresses: http://www.fns.usda.gov/wic and http://www.fns.usda.gov/wic/FMNP/FMNPfaqs.htm

Summer Food Service Program

Provides nutritious breakfasts, lunches, and snacks to ensure that children in lower-income areas continue to receive nutritious meals during long school vacations when they do not have access to school lunch or breakfast. Refer children to local summer programs. Area schools may have information about available programs.

Web address: http://www.summerfood.usda.gov

Community involvement by family physicians also can benefit patients. Initiating the development of a food pantry within a medical clinic or personally assisting the local food bank with a food drive or food recovery project (http://www.usda.gov/news/pubs/gleaning/content.htm) can benefit patients and the community.

TABLE 3

Food Security Information Resources

Information available online

Center for Hunger and Poverty (http://www.centeronhunger.org)

Community Food Security Coalition (http://www.foodsecurity.org)

Food Research and Action Center (http://www.frac.org)

Food Security in the U.S. Briefing Room (http://www.ers.usda.gov/briefing/foodsecurity)

World Hunger Year (http://www.worldhungeryear.org)

U.S. Department of Agriculture Community Food Security Initiative (http://www.reeusda.gov/food_security/foodshp.htm)

World Hunger Site (http://www.thehungersite.com)

TABLE 3   Food Security Information Resources

View Table

TABLE 3

Food Security Information Resources

Information available online

Center for Hunger and Poverty (http://www.centeronhunger.org)

Community Food Security Coalition (http://www.foodsecurity.org)

Food Research and Action Center (http://www.frac.org)

Food Security in the U.S. Briefing Room (http://www.ers.usda.gov/briefing/foodsecurity)

World Hunger Year (http://www.worldhungeryear.org)

U.S. Department of Agriculture Community Food Security Initiative (http://www.reeusda.gov/food_security/foodshp.htm)

World Hunger Site (http://www.thehungersite.com)

Finally, continuing to learn about food insecurity and how it negatively impacts patients is vital. In addition to participating in continuing medical education on the topic, practicing physicians can access information through several organizations (Table 3).

The Authors

David H. Holben, Ph.D., R.D., L.D., is associate professor and director, Didactic Program in Dietetics, at Ohio University College of Health and Human Services, Athens.

Wayne Myles, D.O., practices at Albany Family Medicine, Albany, Ohio, and is part-time faculty at Ohio University College of Osteopathic Medicine, Athens.

Address correspondence to David H. Holben, Ph.D., R.D., L.D., Ohio University College of Health and Human Services, School of Human and Consumer Sciences, Grover Center W324, Athens, OH 45701. Reprints are not available from the authors.

REFERENCES

1. Life Science Research Office. Federation of American Societies for Experimental Biology. Core indicators of nutritional state for difficult to sample populations. J Nutr. 1990;102:1559–60.

2. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to measure household food security, revised 2000. Alexandria, Va.: U.S. Dept of Agriculture, Food and Nutrition Service, 2000.

3. USDA Economic Research Service. Food Security in the United States Briefing Room. Available at: http://www.ers.usda.gov/briefing/foodsecurity.

4. Nord M, Andrews M, Carlson S. Household food security in the United States, 2001 (FANRR35). Alexandria, Va.: Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture, 2003. Accessed online January 3, 2004, at: http://www.ers.usda.gov/publications/FANRR35.

5. Andrews M, Nord M, Bickel G, Carlson S. Household food security in the United States, 1999 (FANRR-8). Alexandria, Va.: Food and Rural Economics Division, Economic Research Service, U.S. Dept. of Agriculture, 2000.

6. Hamelin AM, Habicht JP, Beaudry M. Food insecurity: consequences for the household and broader social implications. J Nutr. 1999;129:525S–8S.

7. Healthy People 2010. Available at: http://www.health.gov/healthypeople.

8. Olson CM, Holben DH. Position of the American Dietetic Association on domestic food and nutrition security. J Am Diet Assoc. 2002;102:1840–7.

9. Holben DH. An overview of food security and its measurement. Nutrition Today. 2002;37:156–62.

10. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79:6–16.

11. Kim M, Ohls J, Cohen R. Hunger in America, 2001. National report prepared for America's Second Harvest. Princeton, N.J.: Mathematica Policy Research, 2001.



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