As health care moves toward a population health paradigm that focuses on keeping people healthy, hospitals and health systems are recognizing the significance of the social determinants of health. Research by the University of Wisconsin Population Health Institute has shown that only 20 percent of health can be attributed to medical care, while social and economic factors account for 40 percent. To improve the health of the communities they serve, hospitals must recognize and address the behavioral, socio-economic and environmental factors that affect health.

Food insecurity is a social determinant of health that health systems should account for in any population health strategy. The U.S. Department of Agriculture defines food insecurity as a household-level economic and social condition of limited or uncertain access to adequate food, with either disrupted eating patterns or reduced food intake.

Trustee talking points

  • The social determinants of health are an increasing focus of hospital boards and executives as they work to improve population health.
  • Food insecurity is one of the most important factors that negatively affects a person’s or a population’s health.
  • Health systems can address food insecurity through patient screenings, community partnerships and education.
  • Hospitals across the country are working to improve access to healthful food and help patients eat better.

Hospitals and health systems can screen patients for food insecurity and partner with community organizations to offer programs and resources that increase access to healthy foods and raise awareness in the community. This briefing discusses the link between food insecurity and health issues, including chronic illness and child development, and the role of hospitals in identifying food-insecure individuals and households. It also outlines strategic considerations and clinical and nonclinical approaches that hospitals and health systems can use to build a healthier community that addresses the physical, behavioral and socio-economic needs of individuals and families and to improve population health.

Hunger and health

Lack of accessible and affordable food is a major population health issue in the United States. In 2015, the U.S. Department of Agriculture found that 12.7 percent of U.S. households — that is, 15.8 million households — were food-insecure at some time during the year. Food insecurity can have permanent effects on the health of all individuals, regardless of age, gender, ethnicity or other demographic characteristics (see Craig Gundersen and James Ziliak, “Food Insecurity and Health Outcomes,” Health Affairs, November 2015).

A community or individual can experience different levels of food insecurity. Food insecurity has multiple dimensions, and those who are food insecure are not necessarily suffering from hunger. Households that experience “very low” food security have very limited food, but some households that have adequate quantities of food can experience “low” food security. Though many families receive aid from the Supplemental Nutrition Assistance Program, SNAP and other federal nutrition programs are unavailable to many patient families and do not provide adequate resources for a healthy diet, even to families who receive those benefits.

Annually, the USDA measures food insecurity through the Food Security Supplement of the U.S. Census Bureau’s Current Population Survey for the Bureau of Labor Statistics. Based on responses from this series of 18 survey questions, households are grouped into one of four categories:

  • High food security: Households face no problems in acquiring adequate food.
  • Marginal food security: Households face some problems in acquiring adequate food, but the quality of food consumption is not jeopardized.
  • Low food security: Households consume low-quality foods, but the quantity of food is insignificantly reduced.
  • Very low food security: Eating patterns are disturbed in households from reduced food intake due to lack of money and resources.

Food insecurity can occur as a result of hunger or limitation of food, lack of nutritious and safe foods, abnormal eating patterns, and consumption of foods with excess calories and carbohydrates. These factors increase the risk of acquiring chronic health conditions such as diabetes and obesity in some age groups, according to the USDA.

Resources

  • Additional resources on food insecurity and other social determinants of health are available from the Health Research & Educational Trust.

Responses from the USDA survey show that families experiencing food insecurity worry food will run out; don’t have enough food; struggle to afford balanced meals; cut the size of meals or skip meals; eat less than they feel they should; feel hungry but do not eat; lose weight; and go full days without eating.

Many physical, behavioral, clinical and socio-economic factors that determine the health and well-being of an individual are associated with food insecurity, making it a significant health care issue.

Impact of food insecurity

Chronic illness: Food insecurity limits people from consuming a balanced diet, increasing their risk of chronic disease and mental illness. Chronic food insecurity can lead to obesity and diabetes. Insufficient food intake or malnutrition can increase the risk of hypertension, asthma, tooth decay, anemia, infection and birth defects; behavioral health issues, including depression, anxiety and emotional imbalance; and stress and starvation.

Lack of access: Food-insecure households strive to eliminate hunger but, due to a lack of finances and resources, are unable to maintain a healthy and balanced diet. The median amount that U.S. households spend on food weekly is $50 per person; food-insecure households, however, spend $37.50 per person (see Project Bread, Hunger in the Community: Ways Hospitals Can Help, UMass Memorial Health Care, 2009). To cope with financial limitations, food-insecure households substitute cheaper, less nutritious food items for healthy foods.

Food insecurity is prevalent in vulnerable, low-income communities and among minority and  immigrant populations as well as disabled individuals. Many vulnerable, low-income neighborhoods have few grocery stores and lack readily available food, limiting access to many basic healthful food items such as fruits and vegetables (see Westat and the Urban Institute, Hunger in America 2014, Feeding America, 2014). Lack of access to full-service grocery stores, nutrition education, convenient and affordable health care, and appropriate housing facilities affects the physical health of individuals and forces them to apply various coping mechanisms to overcome their food insecurity.

Westat and the Urban Institute find that food-insecure households may use coping strategies such as eating food past the expiration date; asking for help from friends and family; watering down food and drinks to make them last longer; purchasing inexpensive, unhealthy food; selling or pawning personal property; and growing their own food.

Coping with food insecurity can lead to spending trade-offs with other household expenses such as utilities, transportation, medical care, housing and education (see Randy Oostra, ProMedica’s Journey: Addressing Hunger as a Health Issue, ProMedica).

Cost of care: Individuals living in food-insecure households are often unable to purchase healthy food, may have been unable to eat regular meals and snacks as recommended for disease management, and may frequently run out of food, leading to poor disease self-management. With health care costs already rising, the cost of assessing and treating individuals who are suffering from food insecurity is also increasing.

Many people with food insecurity suffer from health care issues that increase their expenses for medical care. Increased health care expenses disturb the financial stability of a household. According to Hunger in America 2014, 55 percent of households had unpaid medical bills and 66 percent of households had to make the difficult choice between paying for food or paying for medicine or medical care.

For low-income populations that are already at a higher risk for food insecurity and chronic disease, lack of access to affordable health care may limit them from obtaining appropriate and timely treatment, resulting in worse health status. When that happens, they need more acute health care services, resulting in increased health care expenses, lost work days and more financial trade-offs for the household, perpetuating the cycle of food insecurity.

Child development: For children, food insecurity can increase the likelihood of health issues, some of which may require medical attention. Food insecurity in children has resulted in $1.8 billion in additional child hospitalizations and $5.9 billion in additional special-education services for students in public primary and secondary schools (see Diana Cutts, Food Insecurity and Health, Hennepin County Medical Center, 2015).

According to Gundersen and Ziliak, children experiencing food insecurity may have two to four times more health problems than children from low-income households that are not food-insecure; behavioral issues, such as being less attentive and more aggressive; higher risk of delays in cognitive and social development; low birth weight and high risk of infant mortality; anemia, asthma and poor oral health; increased school absences, reduced concentration and poor performance on cognitive tests; and fatigue, headaches and depression.

The role of hospitals

Hospitals are investing in interventions beyond their communities’ physical and medical health needs and identifying socio-economic factors such as food insecurity as a significant population health issue. The stigma associated with being food-insecure, however, may prevent households from readily discussing the situation with their health care providers or from seeking benefits and services.

For example, adults affected by food insecurity may be reluctant to apply for federal nutrition programs such as SNAP because of pride, citizenship status or fear of being questioned about their ability to provide for their family. The stigma also may prevent many families from seeking information about available resources to prevent or reduce food insecurity.

Many qualifying families are still unaware of beneficiary programs. Only 61 percent of food-insecure households use benefits provided by SNAP or the Special Supplemental Nutrition Program for Women, Infants and Children (see Katherine Susman, Food Insecurity, Health Equity, and Essential Hospitals, Essential Hospitals Institute, 2016).

Because patients trust health care providers for their knowledge and recommendations, encouraging food-insecure individuals and families to seek help may reduce the stigma associated with food insecurity. Hospitals and health care providers can screen for food insecurity; educate their patients about available federal nutrition programs; guide patients and families to local departments of human services during wellness check-ups or visits; connect patients and families with dietitians and nutritionists for counseling services; provide free food or healthy snacks at clinics or on-site food pantries; host summer or year-round feeding programs; enlist patients in free, on-site education classes; promote existing resources such as food trucks, food shelters, food shelves, food pantries, emergency food programs, community kitchens and more; develop on-site food pharmacies, food pantries and community gardens; collaborate with existing groceries, stores and farmers markets; and support or fund the development of local grocery stores and farmers markets.

Clinical approaches: Many hospitals and clinics have integrated the Children’s HealthWatch Hunger Vital Sign — a two-question screening tool based on the USDA’s household food security scale — as part of their annual population health survey given to children and adults at clinical and hospital visits. Asking the following questions in patient surveys helps identify households or individuals experiencing food insecurity:

  • “Within the past 12 months, we worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true or never true for your household?
  • “Within the past 12 months, the food we bought just didn’t last, and we didn’t have money to get more.” Was that often true, sometimes true or never true for your household?

Nonclinical approaches: Hospitals can determine food-insecure populations in the community through their community health needs assessment. By integrating the Children’s HealthWatch Hunger Vital Sign questions within a hospital’s annual population health survey — distributed to collect information on health needs for CHNAs — hospitals can identify the prevalence of food insecurity and prioritize health needs related to food insecurity and food deserts in the community. Hospitals can analyze the community’s capacity to provide access to food, eliminate food insecurity and decrease the prevalence of chronic illnesses caused by it.

Hospitals can also invest in food systems. They can partner with local food organizations such as food banks or trucks, emergency food services, food pantries, grocery stores and farmers markets. Hospitals can raise awareness about food insecurity, assess individuals who are unaware of their food insecurity status and help them access affordable food. They can also financially support food-related programs developed by community organizations and form alliances with state and national food organizations to promote these programs on a larger scale. And they can collaborate with government agencies, food councils and local public health departments to help survey communities for food insecurity.

Building partnerships with organizations in the food industry provides a better perspective on the community and helps identify those who are hungry or food-insecure. In addition, supporting food innovation enhances the food economy through improved access to healthy food options and job creation, thus potentially increasing food security and reducing poverty levels.

Including food systems as partners in the CHNA development process also strengthens engagement between hospitals and various sectors of the community. The Tackling Hunger Project’s guide, Making Food Systems Part of Your Community Health Needs Assessment (Holly Calhoun and Kevin Barnett, 2016), provides an overview of tools and measures for determining the prevalence of food insecurity in a community. The guide also discusses the benefits of collaborating with community organizations to combat food insecurity.

A health care concern

Hospitals and health systems are redefining themselves, focusing on improving the health of their communities beyond physical health status. Because food insecurity is linked to many socio-economic factors, addressing food insecurity as a population health issue highlights other risk factors that challenge individuals and households, including finances, employment, housing and access to resources such as grocery stores or SNAP benefits. Efforts by hospitals and health systems to reduce food insecurity will lead to improved population health, encouraging hospitals to continue addressing determinants of health in their communities.

By screening for food insecurity and hunger, building community partnerships, working to overcome stigmas and providing programs and resources to serve those suffering from hunger, hospitals and health systems can create a healthier environment — an environment that fully encompasses and addresses the community’s physical health, behavioral health and socio-economic needs.

Excerpted, with permission, from the Health Research & Educational Trust's Determinants of Health Series: Food Insecurity and the Role of Hospitals


How social determinants of health affect food insecurity

 

Social determinants of health

Related causes of food insecurity

Related effects of food insecurity

Socio-economic factors

  • Inability to afford healthy foods due to poverty and lack of education.
  • Maximized calorie consumption due to purchasing high-calorie, often low-cost food.
  • Malnutrition.

Physical environment

  • Lack of access to grocery stores and farmers markets with fresh, healthy and shelf-stable foods.
  • Difficulty getting to grocery stores due to lack of transportation or unsafe neighborhoods.
  • Limited consumption of fresh, healthy foods.
  • Unhealthy diet that can lead to chronic diseases.

Clinical care

  • Inability to access health insurance.
  • High costs of health care leading to financial trade-offs.
  • Lack of adherence to recommended dietary guidelines.
  • Irregular eating habits and limited intake of food.
  • High risk of chronic diseases like diabetes, and obesity in some age groups.
  • Difficulty managing chronic diseases such as diabetes, obesity or HIV.
  • Increase in health care costs due to hospital readmissions and medical treatments.
  • Developmental delays in children.
  • Inability to learn and focus, whether at work or school.
  • Increased stress levels and behavioral health issues.

Source: Health Research & Educational Trust, 2017


Clinical approaches to reduce food insecurity

 

Approach

Benefits

Screening patients for food insecurity in physician offices and in outpatient clinics.

  • Identifies people experiencing food insecurity.
  • Allows physicians or other staff to:
  1. Make referrals to support access to healthy food.
  2. Determine whether individuals are aware of and use federal nutrition programs or need information about applying for benefits.
  3. Discuss other associated physical or social conditions.
  4. Educate patients about good nutrition and strategies to improve food security.
  5. Provide tailored clinical care based on a patient’s needs, food security status and financial stability.

Including food insecurity screening in electronic health records

  • Allows food insecurity status to be tracked.
  • Helps identify patients who could benefit from a discussion at their next visit.
  • Allows the use of the appropriate ICD-10 code.
  • Supports data analysis over time to measure readmissions and other health care utilization rates.
  • Helps determine a patient’s eligibility for SNAP, WIC, TANF or the National School Lunch Program.

Distributing food on-site via food pharmacies, food pantries, mobile food pantries and produce markets.

  • Provides patients with immediate access to healthy food.
  • Offers opportunities to collaborate with other health care staff such as dietitians to provide education about healthy eating habits.

Source: Health Research & Educational Trust, 2017


Hospitals stepping up

Eskenazi Health, Indianapolis

Eskenazi Health, which primarily serves people with no insurance, low-income patients and those insured by Medicaid or Medicare, is working to reduce the effects of food insecurity on all age groups.

On the rooftop of Sidney & Lois Eskenazi Hospital in Indianapolis is a garden that is accessible to patients and community members. Many people visit to learn how food grows, discover how to prepare fresh produce and gain a greater understanding of why food is important to health. Open 24 hours a day, seven days a week, the Sky Farm offers large growing spaces for fruits and vegetables that are used in hospital meals and in menu items at the hospital cafe.

Eskenazi has also formed several partnerships with social service organizations that are addressing food insecurity. One of these joint efforts, with Meals on Wheels and the Central Indiana Senior Fund, provides 30 days of free, medically tailored meals to seniors after they leave the hospital. Eskenazi Health hopes this program will help to reduce its current 22 percent readmission rate to 8 percent.

Eskenazi Health also works with the local St. Luke’s United Methodist Church, Dow AgroSciences and Gleaners Food Bank to run food pantries at two locations in disadvantaged areas with food deserts. The pantries are stocked with the help of volunteers from the local, partnering community and faith-based organizations.

Eskenazi joined Gleaners Food Bank to establish Senior Shopping Day, a program that gives residents over age 55 an extra shopping day at the Gleaners Food Bank each month. Gleaners Food Bank provides access to additional low-sodium, low-sugar and high-protein foods. With the help of dietitians, the program is promoting a healthy food focus each month — for example, a low-sodium diet — to educate clients about food and nutrition.

Boston Medical Center

Boston Medical Center became aware of food insecurity in its community after research by the medical center’s Children's HealthWatch program found that existing standards to qualify for nutritional assistance were inadequate. It also found, through patient screenings, that many patients were going to sleep hungry.

BMC started the Preventive Food Pantry in 2001 as a resource for pediatric patients and pregnant women. Over five years, it expanded to include all other departments in the medical center's facilities and now provides food to 1,600 to 1,800 families. It has consistently received a client satisfaction rate of greater than 90 percent.

Clinicians screen patients for food insecurity. If they are found to be eligible, they are referred to the pantry with a prescription for physician-advised meals, helping eliminate the stigma associated with food insecurity. Patients receive a three- to four-day supply, twice a month, for themselves and their families. The pantry is funded entirely through donations from the Greater Boston Food Bank and other community organizations.

Besides the food pantry, BMC addresses food insecurity through an on-site Women, Infants and Children program, assistance in applying for food stamps, gift cards to help patients buy food, and a demonstration kitchen with classes on cooking for cardiac rehabilitation, weight reduction and diabetes.

Arkansas Children’s Hospital

In 2009, Arkansas was ranked No. 1 among U.S. states in childhood hunger. A survey of families visiting the Arkansas Children’s Hospital emergency department confirmed the magnitude of the problem: 20 percent had difficulty accessing food.

In response, the Little Rock hospital has launched several programs to fight hunger among its patients and in the community. One program, a collaboration with the U.S. Department of Agriculture, serves free lunches to children in the hospital and clinics. The lunches help nourish children who need to spend long days receiving care, and they alleviate the cost of purchasing food away from home.

Joining with several community partners, the hospital built a community garden on the hospital campus, providing fresh produce to a neighborhood food pantry. Another partnership has led to classes for patients and the community on preparing affordable and healthful meals.

The hospital has also established an on-site Women, Infants and Children office to help families apply for benefits, while a food pantry bus rolls in once a week to provide groceries for patients. Families who visit one of the hospital’s busiest clinics are screened for food insecurity, and those who are determined to be in need receive referrals as well as a grocery bag filled with food.

In 2016, the hospital garden generated nearly 1 ton of fresh produce, gave out more than 21,000 free lunches and helped 299 visitors to its WIC clinic.


Trustee takeaways

Besides providing clinical and nonclinical resources, hospitals can also provide on-site services to raise awareness about food insecurity and healthy eating, including:

Classes led by health educators: Classes can educate hospital staff about food insecurity and community resources as well as help patients discover low-cost strategies for healthy food choices.

Connections to food resources: Applications for the Supplemental Nutrition Assistance Program, the Special Supplemental Nutrition Program for Women, Infants and Children, and Temporary Assistance for Needy Families benefits can help food-insecure families, as can referrals to local food pantries, emergency food organizations and local departments of health and human services.

Community gardens: Besides allowing families to grow their own produce, community gardens can serve as a catalyst for neighborhood interaction and promote job opportunities. They can also provide free, on-site nutrition education.

Social support groups: Facilitated by culturally competent social workers and public health workers, support groups can help reduce the stigma connected with hunger and food insecurity and also allow food-insecure individuals to reach out to other individuals who struggle with this stigma.