Everything seems fine as I review the chart. My 10:15 a.m. patient is a toddler who has no medical problems and is growing well. When I enter the room, I explain to mom how a child’s health is determined by several factors outside of the doctor’s control, and I ask her to complete a form that all parents fill out during well-child visits. This form screens for a number of social determinants of health, including food insecurity (FI). Even though the child has an intact family and appears well on examination, the completed form is highly positive for FI.
Food Insecurity in the U.S.
Everyone should be worried about food insecurity and its high prevalence in America. One in 6 Americans suffer from hunger in the U.S. This means that over 40 million Americans, including over 16 million children, are affected yearly. The Map the Meal Gap project of Feeding America has data on food insecurity in every county. Hunger is particularly prevalent in areas such as the state of New Mexico, the District of Columbia, and Philadelphia, where more than 25 percent of children are food insecure. It is also clear that FI is not confined to poor urban areas but occurs in suburban and middle-class communities. In fact, it occurs in every single county in the U.S. The prevalence increased throughout the recession (2008–2012), and it remains high in spite of the recovery. So, FI is a huge problem that is not going away.
Most people have felt the “uneasy” or “painful” sensation of hunger caused by skipping a meal or two. However, food insecurity is a severe, extended experience defined by the U.S. Department of Agriculture as “prolonged hunger due to inadequate access to food“. Families with FI have limited or uncertain access to the nutritious, safe foods necessary to lead a healthy life. The experience of FI has a profound impact on children and their families—an impact that all of us should be very concerned about.
The effect that FI has on families can be demonstrated by a three-legged stool described by Maslow. The three legs represent the three basic requirements for a healthy life: shelter, warmth, and food. The top levels of the stool represent many issues that pediatric providers address during visits to their offices, including safety, belonging, love, and self-esteem. When one of the basic needs is threatened, the stool wobbles and can collapse. A lack of food causes collapse of the stool and leads to negative health consequences for children and their families. Indeed, hospitals are uniquely situated to address FI and prevent the stool from collapsing.
More specifically, FI is associated with negative consequences for humans of all ages, from unborn fetuses to adults. Children born to mothers with FI are more likely to have birth defects such as cleft palate or spina bifida and to be small. Studies have shown that infants and toddlers with FI are much more likely to have frequent illnesses and be hospitalized. Even more concerning is that these children are likely to have poorer development than their food secure peers. School-aged children with FI demonstrate more emotional and behavior problems, substandard health, and inferior academic performance. It gets worse. Teenagers with FI also have more anxiety, aggression, depression, and suicide attempts. Yes, suicide attempts. The anxiety and depression symptoms are also found in adults with FI. So, FI causes myriad effects that impact families across the continuum of life.
Although FI is very common and has significant side effects, there are a lot of things we can do to help families in the fight against hunger. Research has shown that medical problems account for only about 20 to 30 percent of a person’s health. Other determinants of health include socioeconomic factors, health behaviors, genetics, and environmental conditions. The importance of addressing not only the medical but also the psychosocial needs of our patients has become quite clear, and health care centers have the opportunity to deal with hunger in innovative ways.
St. Christopher’s Hospital for Children is developing a model that builds upon a framework described by Project Bread. The model provides a way for hospitals to actively address hunger and poor food access in their communities. Hospitals like St. Christopher’s can SPEAC for children and their families by Screening, Providing resources, Educating, Advocating, and Caring for children and families. This model can be combined with other approaches that address poverty and its effects.
St. Christopher’s SPEACs for families by doing the following:
S – We screen for food insecurity and other social determinants of health in our outpatient center (Center for the Urban Child) and track these findings in our electronic health records.
P – We provide a comprehensive set of resources for families. For example, we give families a Resource List that tells them about available benefits, nearby food banks, and other food resources. We have started a fresh produce program with a local food cooperative (Lancaster Farm Fresh Cooperative) and write prescriptions at the bedside to link families to this program. We have a medical-legal partnership onsite to provide families with legal help in pursuing benefits and services. We also hold an annual turkey dinner drive for families, have recruited a WIC Office to reopen on campus, and have started a daily meals program.
E – We educate families and the community about food insecurity and raise awareness of issues and opportunities by using presentations, providing educational DVDs in the waiting rooms, and developing an annual staff training module.
A – We advocate by facilitating systemic change to help families in need. We recruited an onsite WIC Office to serve our families and had the hospital community write SNAP letters of support.
C – We provide holistic, multidisciplinary team care to our families that addresses their medical and other needs.
Using our Hunger-free Healthcare Center model, we have impacted the lives of thousands of children. We have screened over 20,000 patients in the last five years; provided over 7,000 boxes of fresh produce to families; helped families receive over $120,000 in SNAP (food stamps), SS (Social Security), and other benefits; enrolled over 1,000 families in a new WIC (Women, Infants, and Children) office at the hospital; and begun a daily meals program to serve families in the office. We have also educated thousands of staff, families, and providers during our turkey dinner drives, community speaking engagements, and other community events; advocated by getting the WIC office back to the hospital; collaborated with over 15 community organizations; innovatively cared for patients by hiring community health workers, dieticians, a lawyer, and social workers; and developed community partners to provide holistic, integrated, and multidisciplinary team care for our patients.
These are some of the ways that health care centers can help address food insecurity, but there is a role for everyone in the fight against hunger. Individuals can work as food bank volunteers or independently serve meals to homeless families. They can also raise money for food banks. My teenage daughter recognized homeless people on her way to elementary school. As a result, we started an annual food drive to collect food for our local food bank (Philabundance). Not only did this help many families, it taught my daughter about a problem and how to develop solutions to the problem. Another impactful way to help is to support legislation aimed at reducing FI. The WIC and SNAP programs have independently been shown to protect against FI. Unfortunately, these programs have been cut recently, lessening their effectiveness.
So, what did I do for the family mentioned in the opening paragraph? Since the FI questions were positive, I quickly determined that the mother received SNAP benefits but had not applied for WIC benefits because it was too complicated. She also told me she was interested in eating more fruits and vegetables. Once I ordered the immunizations for the child, I printed a copy of our Resource List, which has local food banks where the mother could get food in an emergency. I also gave her a flyer about our WIC office at the hospital and wrote a prescription to link her to our fresh food program (Farm to Families), allowing her to receive a discounted box of local fresh fruits and vegetables (along with recipes and a cooking demonstration) at our hospital. As she left the room, she thanked me for everything and headed off to the WIC office to apply for benefits.
Dr. Hans Kersten, MD FAAP
Dr. Hans Kersten is a Child’s World America board member. He is board certified in pediatrics and is the Medical Director for the Grow Clinic (for children with failure-to-thrive [FTT]) and a pediatrician at St. Christopher’s Hospital for Children in Philadelphia, Pennsylvania. Dr. Kersten is also a Professor of Pediatrics at Drexel University College of Medicine.