Social Determinants of Health (SDOH) are defined as “the conditions in the environment where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” [1] There is greater awareness of health as being more than the absence of disease. Health is impacted by multiple factors that exist beyond the office door and are not always under a clinician’s direct control. The knowledge of these social drivers helps clinicians advocate for their patients and provide personalized care in a manner that is most beneficial for their patients.
One such factor is food insecurity, which has been associated with lower consumption of healthful foods such as fruits and vegetables, and greater consumption of sugar-sweetened drinks and fast food. It has also been shown to be associated with binge eating. [2] Studies suggest a strong association between food insecurity and obesity for women with more mixed results for men and children. [3] The U.S. Department of Agriculture (USDA) defines food insecurity as a “household-level economic and social condition of limited or uncertain access to adequate food.” [3] Several different types of households face higher than average food insecurity rates including those that include children are single parent, are single occupant, are black, are Hispanic, are below 185% of the Federal poverty level, are located in rural areas, and or are in the Southern United States. [4]
Although rates of food insecurity improved from 14.9% in 2011 to 10.5% in 2019 and 2020, the progress made in this direction was undone by the COVID-19 pandemic fallout. [5] There are several federal programs that address food insecurity, such as SNAP (Supplemental Nutritional Assistance Program) and WIC (The Special Supplemental Nutritional Program for Women, Infants, and Children), which provides low-income pregnant women, recently pregnant women and children vouchers to obtain a limited subset of foods which are obtained at local participating retailers. Unfortunately, the utility of these programs is limited by several factors. Enrolling in these programs can often be cumbersome for already constrained individuals who are juggling several jobs, lack transportation, and are raising children. These programs require many in-person visits and regular reporting. Even for individuals who do qualify, the benefit provided is often too low to afford nutritious meals. The formula used has unrealistic assumptions about food costs, regional price differences, time constraints, consumer spending habits, and competing household costs.
Several institutions have incorporated screening for SDOH into their electronic health record systems. This alerts the clinician to be aware of social factors such as food insecurity. Unfortunately, the linkage of these screening tools to community resources is lacking in most places and this limits their usefulness in producing better health outcomes. The Gus Schumacher Nutrition Incentive Program (GusNIP) seeks to address these concerns by providing federal funds for grants and projects that incentivize the consumption of fruits and vegetables by low-income persons. Although financial incentives are one possible tool that may be effective in altering dietary behaviors, more research is needed to identify additional interventions that are effective.
Call to Action
Addressing the impact of food insecurity on obesity requires a system-wide approach. A focus on public policy would help to maximize the effect. Policymakers must look beyond the calories-based view and explore food system-level reform to improve long-term food and nutrition security. Physicians, nurse practitioners, physician assistants, and other medical professionals have a role in improving nutritional health by screening and by serving as connections between patients, community organizations, and government services. Government and payers must support these efforts by providing sufficient resources to practices fulfilling this role.
Community and personal gardens can supply fresh produce in areas where availability is limited due to cost prohibition and supply chain issues. The development of food hubs, which are entities that aggregate, distribute, and sell food from local or regional producers would certainly help in increasing access to healthy foods. According to Feeding America statistics, nearly 40% of all food in the United States is wasted each year ($408 billion). [6] Mechanisms to connect food-insecure individuals with this resource would help bridge the food gap in an environmentally sustainable manner.
Institutions and health systems have a responsibility in this as well and can help by serving as food distribution sites, partnering with local food retailers, organizations, and schools, and investing in community resources and organizations. Beyond implementing screening in practices and hospitals, information about the effect of food insecurity on health, screening tools, and available resources should be integrated into medical education so that clinicians are sufficiently equipped with the skills and knowledge to help their patients. Given the short interaction time between clinicians and patients during an office visit, clinicians must be supported by payers, institutions, the government, and the community in the effort to connect patients with food insecurity to appropriate resources.
