Addressing Food Insecurity to Optimize Nutritional Status

Abstract

Chronic health conditions related to diet are linked with increased risk for COVID-19 infection, complications, and mortality. Adherence to a healthy diet pattern can be protective, but a major barrier to healthy eating is the high cost of healthy foods. Access to healthy foods is especially limited in households that experience food insecurity, not having enough food or resources to get food. Individuals who live in these households are also at increased risk for a number of health conditions. Addressing food insecurity within lifestyle medicine practice is needed to achieve optimal nutrition status. Emerging food as medicine and other food access programs are promising but coverage of such programs is lacking through healthcare insurers. Medicaid waivers are a potential solution and have been utilized in a handful of states.

This study addresses the limited access to affordable healthy food among individuals with low income that causes chronic health conditions.

COVID-19

Chronic health conditions such as obesity, type 2 diabetes, and cardiovascular disease have also been linked with increased risk for COVID-19 infection and mortality. ¹ Dietary intake and nutritional status are key determinants of chronic health conditions. Nutrition interventions have the potential for reducing the risk for COVID-19 infection. ² Nutrition interventions aim to improve adherence to healthy dietary patterns. These healthy dietary patterns are rich in plant-based foods (i.e., fruits, vegetables, legumes, and whole grains), lean sources of protein and dairy, and are lower in intake of processed foods with added salt, fat, and sugar. Adherence to these dietary patterns across the United States is low. ³ A number of factors influence an individual’s’ ability to adhere to this dietary pattern.

A recent study of Supplemental Nutrition Assistance Program (SNAP) participants found that nearly 90% of survey respondents experienced challenges to a healthy diet with the high cost of healthy food being the most frequently reported barrier (60%). ⁴ The affordability of healthy foods creates an even greater barrier to a healthy diet in the face of food insecurity. Food insecurity is defined as a household that if in some time during the last year did not have enough food, money, or resources to feed the family. In 2020, 1 in ten households across the US experienced food insecurity, whereas food insecurity was increased in households with children (14.8%), households with children under 6 years (15.3%), households with Black, non-Hispanic (21.7%), and Hispanic (17.2%) persons, and households with incomes below 185% of the poverty thresholds (28.6%). ⁵ Food insecurity has negative consequences on children: increasing risk for anemia, having poor health, and asthma; in adults, it is associated with decreased nutrient intake, increased rates of mental health and depression, diabetes, hypertension, hyperlipidemia and poor sleep; and in older adults (>65 years), it is associated with lower nutrient intake, depression, and limitations to activities of daily living. ⁶

Healthcare providers have an opportunity to address diet, food insecurity, and health through new and emerging healthy food prescription and incentive programs. Addressing food insecurity in primary care and lifestyle medicine interventions is happening through the food as medicine or “medically tailored nutrition” movement. Through these programs, healthcare providers screen their patients for food insecurity and offer vouchers to purchase fresh fruits and vegetables from approved retailers. The growing body of evidence in support of these programs has shown their potential to improve food insecurity, diet, health, and reduce healthcare costs.

Fruit and vegetable (FV) vouchers, as little as US$11 per month, have been found to be effective in increasing FV intake and reducing food insecurity in low-income children and adults who participate in the federally funded Supplemental Nutrition Program for Women, Infants, and Children (WIC) program. ⁷ The WIC program observed a significant increase in FV purchases and consumption when FV vouchers were introduced. WIC participants who used vouchers at farmers’ markets were twice as likely to consume the recommended number of FV servings per day (OR = 2.01, 95% CI = 1.15-3.5). ⁸ In another study, the Wholesome Wave FV Rx program provided FV vouchers to predominantly Hispanic or Latino families (64.7%) of obese children through healthcare providers at 9 federally qualified health centers across the United States. ⁹ There was a positive and significant shift in households reporting high food security status (58% vs 76%). ⁹ Healthcare providers are a potential and underused resource for screening and providing resources to address food insecurity and other social determinants of health such as food access. ¹⁰ One study found that a 30% subsidy on fruits and vegetables over a lifetime could yield a savings in US$39.7 billion in healthcare costs for Medicare and Medicaid participants. ¹¹ This evidence suggests increasing FV access through vouchers can positively affect FV consumption and food security status. To date, the majority of programs have been covered on a grant basis, one of the largest funders being the United States Department of Agriculture’s Gus Shumacher Nutrition Incentive Program (GUSNIP), formerly known as the Food Insecurity Nutrition Incentive Program (FINI). A factor limiting implementation of these programs is sustainable funding, which could come in the form of reimbursement by health insurers.

The largest health insurance provider of individuals at risk for food insecurity is Medicaid. Medicaid agencies across the country have taken advantage of various strategies to pay for nutrition services and food access. Medicaid waivers provide states with the opportunity to support interventions that increase access to healthy food. States can apply for 1 of 3 different types of waivers through Centers for Medicaid Services to implement innovative policies and provide benefits that might not be allowed under federal guidelines. In North Carolina, since 2018, a Medicaid waiver has authorized a program called the “Healthy Opportunities Pilots.”^12,13 The program tests interventions that address issues, such as transportation and food insecurity, to improve health. Through this program, 29 different services have been defined, including a service rate and definition. Nearly one-third of the services are specifically related to address food security through fruit and vegetable prescriptions, food boxes, and medically tailored meals delivered to homes.

Lifestyle Medicine and Addressing Food Insecurity

Addressing issues around food insecurity is foundational to lifestyle medicine interventions that aim to improve diet and nutrition. Regardless of the availability of Medicaid reimbursement for these services in the healthcare providers’ state, one best practice for implementation is screening for food insecurity. A simple 2-question screener has been validated to identify individuals at risk for food insecurity. Providers can ask if either of the following statements were often true, sometimes true, or never true in the last 12 months: “We worried whether our food would run out before we got money to buy more” and “The food we bought just didn’t last and we didn’t have money to get more.” ¹⁴ Once identified, healthcare providers can use the ICD-10-CM diagnosis code Z59.4, “lack of adequate food” and provide referrals to local food banks and support in applying for benefits for food assistance programs. ¹⁵

Nutrition interventions are a viable solution to reducing risk for COVID-19. Interventions should seek to address the underlying etiology contributing to poor dietary intake among patients. Access to affordable and healthy food is a commonly cited barrier among individuals with low income. Food as medicine programs include those that offer vouchers to obtain healthy food, medically tailored meals, and healthy food boxes have demonstrated positive impacts on food insecurity, dietary intake, and health outcomes. Healthcare providers can screen for food security, document the condition, and provide referrals to available food access programs. At a state level, healthcare providers can provide input, through community engagement processes, to obtain Medicaid waivers that may aid in covering the cost of food as medicine programs.