Editorial – Gregory Lewis, MD, FAAFP

Social Determinants of Health – Food Insecurity – Editorial Series Part II

Social Determinants of Health (SDoH) are the conditions under which people are born, grow, live, work and age¹.  They have a larger role on population health than more traditional factors like genetics, behavior and health care².  Examples include socioeconomic status, education, employment, social networks, racism, discrimination, residential location, and housing and food security.  These upstream factors create the structure for health inequalities.  This is the second part of an editorial series on SDoH, today focused on food insecurity.

The United States Department of Agriculture (USDA) notes food insecurity of two subtypes.  Low food security is when there is a reduction in the quality or desirability of diet, with no significant reduction of food intake.  Very low food security is when there are disrupted eating patterns with reduced food intake³.  In a December 2017 survey, the USDA noted approximately 88% of U.S. households were food secure, 7.3% were with low food security and 4.5% with very low food security⁴.  In another survey from 2015 in Los Angeles County, the impact of income on food insecurity is quite apparent.  In households with income of 300% of the Federal Poverty Level (FPL), total food insecurity impacted 29.2% of this population; household income of 100% of the FPL, the percentage impacted rose to 41.1%³.

Individuals with food insecurity often rely upon cheaper, more energy-dense and nutrient-poor foods and beverages to avoid hunger.  These are higher in calories, sodium and sugar.  Fresh produce is less available and more expensive in poorer communities⁵.  We are all aware of the association of dietary practices and chronic medical problems like diabetes, high cholesterol, hypertension and even depression.  A study from 2017 noted food insecurity is associated with behavioral, academic and emotional problems from infancy through adolescence⁶.

Medical providers and organizations, in partnership with the community, may be able to make a difference.  The American Academy of Pediatrics released a policy statement in October 2015, recommending screening for food insecurity at health maintenance visits.  The “Hunger Vital Sign” has been validated for use in youth, adolescents and adults⁷.  The CAFP adopted policy last year screening for food insecurity in healthcare settings.  The AAFP has a tool “Neighborhood Navigator” as part of The EveryONE Project, to help providers connect patients with local programs to address food insecurity⁸.  Studies are gradually emerging that support programs like the Supplemental Nutrition Assistance Program (SNAP) and the Double Up Food Bucks program may help to change medical outcomes and healthier food purchases^{5, 9}.

As stated in my last editorial, as Family Physicians we are on the front line to have an impact on these upstream issues.  Much further, well-designed research needs to be done on programs addressing food insecurity.  We generally should follow evidence-based guidelines when such exists.  As physicians, we have opportunities and platforms to advocate for social reform on many local, state and national levels.  We need to take action in our own practices and our communities.

1. American Academy of Family Physicians.  Social determinants of health policy.  https://www.aafp.org/about/policies/all/social-determinants.html
2. American Academy of Family Physicians.  Advancing Health Equity by Addressing Social Determinants of Health in Family Medicine (Position Paper).  https://www.aafp.org/about/policies/all/socialdeterminantofhealth-positionpaper.html
3. Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology, Food Insecurity in Los Angeles County, September 2017. http://www.publichealth.lacounty.gov/ha/docs/2015LACHS/LA_Health_Briefs_2018/FoodInsecurity_REV2018.pdf
4. USDA, Economic Research Service, Current Population Survey, Food Security Supplement, December 2017.
5. Rummo PE, et. al.  Evaluating a USDA program that gives SNAP participants financial incentives to buy fresh produce in supermarkets.  Health Affairs. Nov 2019; 38(11): 1816-1823. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00431
6. Shankar P, Chung R, Frank DA.  Association of food insecurity with children’s behavioral, emotional and academic outcomes: a systematic review. J Dev Behav Pediatr. 2017 Feb/Mar; 38(2): 135-150.
7. Baer TE, et. al.  Food insecurity and the burden of health-related social problems in an urban youth population.  Journal of Adolescent Health.  57 (2015): 601-607.
8. Neighborhood Navigator (AAFP).  https://www.aafp.org/patient-care/social-determinants-of-health/everyone-project/neighborhood-navigator.html
9. Heflin CM, Ingram SJ, Ziliak JP.  The effect of the supplemental nutrition assistance program on mortality.  Health Affairs. Nov 2019; 38(11): 1807-1815. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00405