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Addressing Food Insecurity in Family Medicine and Medical Education

Sunny Smith, MD; David Malinak, MD; Jinnie Chang, BA; Amanda Schultz, MPH; Kristin Brownell, MD, MPH

Background and Objectives: Food insecurity is associated with poor health outcomes, yet is not routinely addressed in health care. This study was conducted to determine if education regarding food insecurity as a health issue could modify knowledge, attitudes, and clinical behavior.

Methods: Educational sessions on food insecurity and its impact on health were conducted in 2015 at three different family medicine residency programs and one medical school. A pre/post survey was given immediately before and after this session. Attendees were encouraged to identify and implement individual and system-based changes to integrate food insecurity screening and referrals into their clinical practices. Participants completed follow-up surveys approximately 1 year later, and the authors obtained systems-level data from electronic health records and databases. Pre/post means (SD) were compared using t-tests. The numbers of patients screened and referred were calculated.

Results: Eighty-five participants completed the pre/post survey during the educational sessions (51 medical students, 29 residents, 5 faculty). Self-reported knowledge of food insecurity, resources, and willingness to discuss with patients increased (P<0.0001 for all). Each program identified a feasible systems-based change. Follow-up surveys demonstrated increased discussion of food insecurity during clinical visits and referrals to food resources. Over 1,600 patients were screened for food insecurity as a result of systems-based changes.

Conclusions: Educational interventions focused on the role of food insecurity in health can produce improvements in knowledge and attitudes toward addressing food insecurity, increase discussions with patients about food insecurity, and result in measurable patient and systems-level changes.

(Fam Med. 2017;49(10):765-71.)

Food security means that all members of a household have access to enough food at all times to maintain an active and healthy life.1 In contrast, food insecurity is defined as limited or uncertain access to nutritiously adequate food.1,2 The US Department of Agriculture (USDA) routinely measures household food security, and differentiates food insecurity from hunger.1 While hunger is a multifactorial physiologic experience of an individual, food insecurity refers to a household’s impaired access to nutritious foods, which often coexists with unhealthy dietary habits.

Traditional images of people without access to sufficient nutritious foods may include underweight or malnourished individuals in developing countries, during episodic famine, in times of war, extreme poverty, or during the Great Depression. However, in 2014 there were approximately 48 million food insecure people living in the United States (14% of the population), and the historical images of food insecurity generally do not apply here.3 Episodic or chronic food insecurity in the United States and Canada does not typically result in readily recognizable clinical syndromes.

Physicians routinely counsel patients to eat a healthier diet, including increasing the amount of fresh fruits and vegetables, without considering that these are the least affordable foods.4 Low-income families would have to spend up to 70% of their monthly food budget on fruits and vegetables to follow the USDA recommended food plans.5 Limited household food budgets practically ensure that families will have to choose energy-dense foods with low nutrient content.6 Food insecurity is associated with many poor health outcomes throughout the lifespan.7,8 Food insecure individuals are more likely to have hypertension, hyperlipidemia, diabetes, depression, and suicidal ideation.9-14 Nearly half of patients with diabetes seeking care at low-income clinics were food insecure.15

Although medical education routinely teaches the importance of obtaining a social history, which sometimes includes a dietary history, we have not traditionally taught medical students, residents, or physicians to ask patients if they have enough food to eat, much less how to ask that sensitive question.16 Patients are unlikely to bring up the inability to provide food for their families due to shame, stigma, and social norms, as this has not been an issue typically addressed in the health care setting. With providers and patients both unlikely to discuss food insecurity, this has been an underrecognized and undertreated issue in medical care.17,18

The American Academy of Pediatrics (AAP) released a policy statement in December 2015 urging practicing clinicians to screen all children for food insecurity.8 The AAP specifically encouraged teaching medical students and residents to regularly screen for food insecurity. The American Diabetes Association (ADA) recently added a section on managing food-insecure patients to their Standards of Medical Care in Diabetes 2016.19 The ADA noted that patients with limited access to food are at risk for hypoglycemia as well as hyperglycemia, and recommended that clinicians seek local resources to help patients obtain nutritious foods.19 Education on food insecurity has been demonstrated to increase pediatric resident identification of food insecurity.20

This study was conducted to determine if brief educational interventions on the physician’s role in addressing food insecurity could improve awareness of food insecurity, its impact on health, and result in change in clinical practices.

 

Methods

 
 

Study Population

The study population included family medicine residents and faculty from three residencies in San Diego County and medical students from the University of California San Diego (UCSD). UCSD Family Medicine Residency is based in an academic medical center. Scripps Chula Vista Family Medicine Residency is a community-based program affiliated with UCSD, and Family Health Centers of San Diego is a teaching health center based in a federally qualified health center. The study also included medical students from the preclinical elective course associated with the UCSD Student-Run Free Clinic Project (SRFCP).23 Participants included those who were present during protected resident or medical student didactic educational sessions.

Survey Design

A literature review revealed no well-validated survey instruments to measure knowledge, skills, attitudes, or clinical practices in health care practitioners or trainees related to food insecurity.

Faculty and medical students worked alongside a community-based hunger organization (San Diego Hunger Coalition) and a large food bank (Feeding San Diego) to learn more about hunger issues in San Diego and best practices for food insecurity assessment and referrals. We then designed a survey instrument for use in this project. Food insecurity experts reviewed the draft instrument, provided input, and helped revise the survey. The survey was then piloted with a small group of residents. Cronbach’s alpha estimate for internal reliability for the presurvey was 0.81 and 0.83 for the postsurvey.

Intervention

The authors created a 30 to 50 minute presentation that was delivered from January through July 2015 using a traditional lecture-based format, but also encouraged discussion throughout. Learning objectives are listed in Table 1. Toward the end of the session, participants were asked to discuss how they might approach addressing food insecurity in their clinical practice, and what systems-based changes might be possible.

 

Table 1

 

Survey Administration

All faculty, residents, or medical students present at didactics were handed a paper survey at the beginning of the session. Participants completed the pre/post survey immediately before and after the session and returned it the same day.

Approximately 1 year later, in June and July of 2016, residents and faculty were asked to fill out a final follow-up survey on paper during their routine educational half day to assess any lasting impact. We emailed a link to a web-based survey instrument to medical students as they were dispersed on clinical rotations. We contacted faculty members and representatives of health care systems to obtain information regarding systems-based program changes and number of patients screened or referred, if available.

Data Analysis

Cronbach’s alpha was determined for internal consistency. We calculated means and standard deviations for each survey item. For five-point Likert scale items we determined the percentage of each response. Pre/posttest scores were compared using t-tests. To assess systems-based changes, we inquired with program leadership and queried electronic health records (EHR) and registries used for tracking food insecurity screening or referrals, if available. Food insecurity screening tools included the USDA six-item food security survey that allows for classification of level of food insecurity and an abbreviated two-item survey that has been well validated and is considered easiest for use in clinical practice.8,24,25 We calculated the total number of pounds and retail value of food distributed since the implementation of the new systems-based changes. Excel 14.2.5 (Microsoft Inc, Redmond, Washington) and SPSS 22.0 (IBM Armonk, New York) were used for all calculations. The UCSD institutional review board certified this study as exempt.

 

Results

 
 

Across the four sites, 85 study participants (51 medical students, 29 residents, and five faculty members) completed the intervention.

Before the educational sessions, 95.3% (81/85) of participants agreed or strongly agreed that it is important to assess low-income patients for food insecurity, 94.1% (80/85) of participants agreed or strongly agreed that it is important to refer low-income patients to food resources, and 89.4% (76/85) agreed or strongly agreed that food insecurity was relevant to their patient population. However, only 17.7% (15/85) often or always asked their patients about food insecurity and 51.8% (44/85) had rarely or never asked their patients about food insecurity. Most had never or rarely referred their patients to a food bank (63/85; 74.1%) or to Supplemental Nutritional Assistance Program (SNAP, [64/85; 75.3%]), which is referred to as CalFresh in California, and was formerly known as food stamps.

Mean scores for each Likert scale item including knowledge of food insecurity, food resources, importance, relevance, and willingness to ask increased significantly from baseline to the immediate postintervention survey (P<0.0001, Table 2). When examined separately based on level of training, each group had significant improvements, therefore data was reported as a group.

 

table2

 

Approximately 1 year after the initial survey, the response rate of initial participants was 75.9% (22/29) for residents, 100% (5/5) for faculty, and 25.5% (13/51) for medical students. Medical student data was not included in the 1-year follow-up analysis due to low response rate. Baseline, immediate postintervention, and 1-year outcomes for residents and faculty are presented in Table 3. Self-reported knowledge regarding food insecurity remained improved 1 year later. Residents and faculty reported asking their patients about food insecurity and referring to appropriate resources more often.

 

table3

 

Individual and Systems-Level Changes

Each program was able to identify a systems-level change that seemed feasible and appropriate for their setting (Table 4).

 

table4

 

At the UCSD SRFCP, a team of prehealth volunteers was recruited to assist with food insecurity screening that began in January 2015. This team successfully implemented a universal food insecurity screening and referral program using the USDA six-item screening tool, with a screening rate of 92.5% (430/456 patients seen had a food insecurity screening score recorded).26 A detailed description of this food insecurity screening program including the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework designed to enhance the quality and public health impact translating research into practice is available.26 Two lead medical students collaborated with San Diego Hunger Coalition, Feeding San Diego, the County of San Diego, and Third Avenue Charitable Organization to implement a pilot, same-day, on-site Cal-Fresh enrollment for hard to reach populations, including homeless individuals and families with mixed immigration status. This same-day enrollment program has resulted in over 150 individuals receiving Cal-Fresh benefits to date.27 Prehealth volunteers, medical students, and faculty worked alongside San Diego Hunger Coalition and Feeding San Diego to create and implement a program that delivered monthly boxes of nutritious foods to over 200 diabetic patients on-site at the free clinic sites and examined the impact of this intervention. Due to the success of the initial diabetes food box program, the clinics expanded into a clinic-based food pantry or food prescription model in July 2016, where all patients now receive fresh produce as well as healthy nonperishable items on-site free of charge as part of clinic visits. Over 100,000 pounds of food has been provided by Feeding San Diego to free clinic patients on-site as a result of this program, with a retail value of over $170,000.

One residency program decided in February 2015 that they wanted to implement a universal food insecurity screening and referral program as a residency quality improvement project. Residents and faculty met with health care organization leadership and obtained approval to pilot this food insecurity screening program at their continuity clinic site. They successfully advocated for their home grown EHR to be modified to include a two-item food security screening tool that was successfully implemented in November 2015.8,25 This two-item food insecurity screening questionnaire asks (1) “Within the past 12 months, we worried whether our food would run out before we got money to buy more” and (2) “Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.”25 Response options include: often true, sometimes true, or never true. A positive response to either question is sensitive (97%) and specific (83%) for food insecurity, and is therefore considered a positive screen.25 Patients within the residency continuity clinic completed paper or verbal screenings after check-in. These forms were available in four languages. Medical assistants transferred results into the EHR. Positive screenings automatically generated an ICD-10 code for food insecurity in the EHR and created referrals for local food pantries and on-site CalFresh application. Query of the EHR revealed that 2,720 patients were seen during the first year of food insecurity screening, 1,196 had food insecurity screening results recorded (44.0%), and 229 referrals were generated from these screenings.

A second residency program identified that a form provided by the state of California for complete physical exams for patients on Medicaid (known as Medi-Cal in California) included several items related to food insecurity (such as “Are you easily able to get enough healthy food?” and “Do you eat fruits and vegetables every day?”).28 Rather than implement their own separate food insecurity screening, they agreed that residents and faculty would routinely review the items already included on this form, discuss food security with their patients, and refer to Cal-Fresh and local food resources when indicated. This led them to identify local food pantry resources, including a food pantry next door to their clinic. Medi-Cal surveys are routinely scanned into the EHR but are not easily queried, therefore we have been unable to quantify patient-level results in this program thus far. On-site CalFresh applications will soon be available in this network of community health centers.

The third residency program decided that initial food insecurity efforts should be made in the locations that serve the highest percentage of low-income patients, including two clinics and the inpatient family medicine service. Residents based in a clinic serving people affected by homelessness stated they would routinely refer to on-site assistance for CalFresh applications as well as the on-site meal program. Residents obtained food pantry and CalFresh handouts for their other low-
income clinic, where neither on-site CalFresh application assistance nor social work assistance were available. Residents identified that routine nutrition assessments were being conducted on the family medicine inpatient service as part of a hospital-wide program, and suggested conducting food security screening at the same time. Nutritionists and dieticians from this program are working toward implementing food insecurity screening for inpatients. Financial counselors began screening for CalFresh eligibility and enrolling patients while admitted. Finally, in 2017, a resident implemented food insecurity screening by adding the two-item screening questionnaire to existing forms at check-in as her clinic project. Medical assistants and licensed vocational nurses use a smart phrase that was created for use in the EHR (EPIC) to record results. Any positive response generates instructions to contact 211 San Diego for food resources in the After Visit Summary (AVS).

Given the success the initial interventions, San Diego Hunger Coalition (including author AS) began other pilot projects to address food insecurity in health care with San Diego County Public Health and hospitals.29 They engaged the Institute of Public Health at San Diego State University and the Hospital Association of San Diego and Imperial Counties to include food insecurity in the 2016 Community Health Needs Assessment for San Diego County.30 This assessment subsequently identified “food insecurity and access to healthy food” as the top priority in the social determinants of health to be addressed by hospitals and community collaborations.30 Efforts are now underway to begin to address food insecurity throughout San Diego County in multiple health care systems.

 

Discussion

 
 

Nearly all medical students, residents, and faculty who participated in this study felt it was important to address food insecurity with lowincome patients at baseline. However, very few had assessed patients for food insecurity or made referrals. This study adds to the literature that demonstrates that health care professionals and trainees lack sufficient knowledge regarding the impact that food insecurity can have on health and their ability to address this issue with patients.31

Educational interventions increased knowledge regarding the importance of food insecurity and the ability of health care providers and trainees to make appropriate referrals. This also allowed medical students, residents, and faculty to reflect upon the role of food insecurity in their patient population, and to propose solutions that might work in their setting. Along with support from the authors as needed, they then implemented individual and systems-based changes that resulted in over 1,600 patients being screened for food insecurity thus far and referred to appropriate resources when indicated.

This study describes several ways in which medical students, residents, faculty, and staff can work together with hunger relief organizations and government agencies to identify the most appropriate methods to start addressing food insecurity in their health care systems. Hunger relief advocacy organizations and food banks are natural partners for clinics and hospitals to approach to devise regional approaches to addressing food insecurity in health care. Many resources already exist for food assistance, including the Special Supplemental Nutrition Program for Women Infants and Children (WIC), National School Lunch Program, Summer Food Service Program, SNAP, and a large network of food banks throughout the country.12 Best practices for referrals to food assistance in health care include providing resources on site, including application assistance or colocating a food pantry within a clinical setting, to overcome the many barriers to successfully obtaining food assistance.29 Referrals to off-site resources are a step in the right direction, but results in lower referral completion rates.29

This study demonstrates that trainees and faculty can easily learn the importance of food insecurity, identify ways in which they may change the systems in which they work, or change their approach to patients to address the fundamental need for adequate nutrition. Without asking patients if they have adequate access to nutritional foods, much of the counseling on dietary changes that we provide our patients is implausible.5,6 We recommend that the social history of the medical interview be expanded to include routine questions regarding food security. This would allow providers not only to refer to appropriate resources, but also to counsel patients specifically on how to eat healthy while on a restricted budget.

Limitations of this study include that it was conducted in one county in California. However, it was conducted at three different residency programs representing university-based, university-affiliated, and teaching health center residency models as well as a medical student-run free clinic. It is possible that a particular food insecurity champion was needed to ensure this intervention was effective, however a varying composition of leaders participated in each session and no one person was present for all sessions. Self-reported survey data may have inherent bias. However, we were also able to obtain objective numbers of patients screened or referred based on patient registries and EHRs, verifying systems-level changes. Finally, the response rate for medical students at one year was low since they had transitioned to clinical rotations. During the 2 years since the inception of this project, there has been an increase in awareness of food insecurity as a health issue nationwide with the release of the AAP position statement on food insecurity. It is not possible to separate the impact attributable to these interventions versus increased societal awareness.

Future areas of inquiry include examining the impact of food insecurity education in other settings, including other medical schools and residency programs. Assessment of patient experience, success of referrals, and change in household food insecurity over time are important areas of further study.

Acknowledgments:The authors would like to thank Feeding San Diego, including Jennifer Seneor and Kelcey Ellis, San Diego Hunger Coalition, the dedicated students, staff and volunteers of the UCSD SRFCP, Steve Niemiec, MD for identifying food insecurity as an important issue to be addressed and beginning the work that lead to this project, Hilary Seligman for offering her expertise to advise us on this project, Jim Lovell and Charlene Atkins for their years of social work expertise and support, Isabel Dominguez and Maria Esmeralda Preval who are outstanding community health promoters, Michelle Johnson, MD and Natalie Rodriguez, MD for their outstanding ongoing clinical care, mentoring, and role modeling at the UCSD SRFCP, Ellen Beck, MD for creating and sustaining this project for 20 years, and Jeremy Egnatios who dedicated his time and energy to an earlier version of this paper with his characteristic passion and energy always reminding us the importance of advocating for social justice at the individual and institutional level.

Previous presentations: Prior versions of this data were presented at the University of California, San Diego Public Health Research Day La Jolla, CA, April, 2015; American Association of Family Physicians National Conference of Family Medicine Residents and Medical Students Kansas City, MO, August 2015; Network of Ethnic Physician Organizations and California Medical Association Building Healthy Communities Summit, Riverside, CA ,September 2015; Society of Student-Run Free Clinics in Phoenix, AZ, February 2016; and Society of Teachers of Family Medicine Annual Spring Conference, Minneapolis, MN, April 2016; and California Academy of Family Physicians Clinical Forum in San Francisco, CA, April 2016.

Corresponding Author: Address correspondence to Dr Sunny Smith, 9500 Gilman Drive #0696, La Jolla, CA 92093-0696. 853-534-6160. Fax: 858-822-3990.
sdsmith@ucsd.edu.

 

References

 
 
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From the Department of Family Medicine and Public Health (Drs Smith and Brownell), Internal Medicine (Dr Malinak) and School of Medicine (Ms Chang), University of California, San Diego; San Diego Hunger Coalition (Ms Schultz); and Family Health Centers of San Diego Family Medicine Residency Program (Dr Brownell).

 

Copyright 2018 by Society of Teachers of Family Medicine