Food insecurity in the United States: its effect on our patients

Food insecurity in the United States: its effect on our patients – Editorial

David H. Holben

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)

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 Harvest (11) 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.

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 ( gleaning/content.htm) can benefit patients and the community.

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).


Food Security Factors to Consider During an Office Visit

Possible resources/treatment plan

Factors considerations

Availability of resources Money for medication or food;

necessary for implementing availability of appliances

the prescribed medical care (refrigerator, freezer);

availability of utilities (natural

or propane gas, electric, water);

availability of transportation

Participation in food assistance Federal programs (Food Stamps,

programs National School Lunch, Special

Supplemental Nutrition Program for

Women, Infants, and Children); food

pantries, soup kitchens, community

gardens, and other non-Federal


Other means of acquiring food Gardening, hunting for game or fish

Nutrition education to help Meal planning and purchasing tips;

preserve food resources and label-reading tips (meaning of

reduce food waste manufacturers’ expiration codes and

other dates on packages); food

safety education (e.g., safe food

preservation tips)


Food Assistance Programs

Program summary, referral

information, and Web site

Programs 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 state education agency.

Refer clients directly to

programs in the community.

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



Expanded Food and Nutrition Helps limited-income families and

Education Program youth acquire knowledge,

skills, attitudes, and behavior

changes necessary to maintain

nutritionally sound diets and

enhance personal development

(basic nutrition, food prepa-

ration, resource management).

Refer clients to the county

extension office.

Web address: http://www.reeusda.


Food Distribution Programs such Overall, these programs support

as: Child Nutrition Commodity the nutrition safety net

Support; Nutrition Services through commodity distribution

Incentive Program (formerly the and other nutrition assistance

Nutrition Program for the to low-income families,

Elderly); Commodity Supplemental emergency feeding programs,

Food Program; Food Assistance in Indian reservations, and the

Disaster Situations; Food elderly. Refer clients to local

Distribution Program on Indian food banks and pantries or

Reservations; the Emergency Food other agencies/ organizations,

Assistance Program; State including faith-based groups,

Processing Program; Nutrition where supplemental foods are

Assistance Program for Puerto distributed. Your local food

Rico, American Samoa, and the bank can be accessed through

Northern Marianas; and Homeless America’s Second Harvest.

Children Nutrition Program Web addresses:


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.

National Meals on Wheels Dedicated to the delivery of

Foundation 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.national

National School Lunch and School Provides nutritionally balanced,

Breakfast Programs low-cost or free breakfasts

and lunches to children

enrolled in public and non-

profit private schools and

residential child care insti-

tutions. Also provides snacks

served in after-school educa-

tional and enrichment programs

for children through 18 years

of age. Refer patients to local


Web addresses: http://www.fns.



Senior Farmers’ Market Nutrition Provides low-income seniors with

Program 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.



Special Supplemental Nutrition Provides supplemental foods,

Program for Women, Infants, and nutrition education and counse-

Children (WIC) and WIC Farmers’ ling, and access to health

Market Nutrition Program 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 nutri-

tional 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


Web addresses: http://www.fns. and http://www.


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


Web address: http://www.summer


Food Security Information Resources

Information available online

Center for Hunger and Poverty


Community Food Security Coalition


Food Research and Action Center


Food Security in the U.S. Briefing Room


World Hunger Year


U.S. Department of Agriculture Community Food

Security Initiative (


World Hunger Site (


(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:

(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:

(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.

(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.

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.

COPYRIGHT 2004 American Academy of Family Physicians

COPYRIGHT 2004 Gale Group