Screening for Food Insecurity in Canadians

Household food insecurity is a serious public health problem in Canada.¹ In addition to being associated with poor physical and mental health outcomes,^2,3 the stress endured by children from food-insecure households predisposes them to a cascade of disadvantages.⁴ Implementing a strategy focused on high-risk children whereby healthcare practitioners, including Canadian physicians and pediatricians, routinely screen their patients for food insecurity may improve clinical management and mitigate the long-term consequences of food insecurity on health. A significant concern is the disparaging lack of services available to individuals who are experiencing food insecurity. In this article, I discuss the pros and cons of screening patients for food insecurity in Canada and argue in favour of patient screening.

Food insecurity – insufficient access to food due to financial constraints – is a significant health problem in Canada.1 Per the 2012 Canadian Community Health Survey (CCHS), four million individuals were food insecure, one million of whom were children.⁵ Although certain jurisdictions decided to opt out of measuring food insecurity in the 2014 CCHS, food insecurity still appeared to be high among Canadians.⁶ Single-parent households and families with children had the highest rates of food insecurity.⁵ Not having enough money for food not only disturbs nutritional intake,⁷ but it is also associated with a vast range of adverse short- and long-term health outcomes, including depression, anxiety, poor academic achievement and economic success.^4,8–10 Although parents may restrict their own intake to ensure adequate food for their children,¹¹ children and adolescents living in food-insecure households face a greater risk of developing a slew of detrimental outcomes: nutritional deficiency, particularly iron deficiency,^8,12 childhood obesity,¹³ childhood asthma,¹⁴ behavioural and developmental problems,^15–18 reduced academic achievement,¹⁰ depression and suicidal ideation,¹⁹ and chronic illnesses.^20–22 In addition, food insecurity makes both healthy eating and physical activity much more challenging.^{7, 23–27} Therefore, the issue of food insecurity in Canada is substantial and requires immediate intervention.

Patient screening for food insecurity in Canada is a high-risk strategy used to identify individuals who are struggling to reach or maintain sufficient intake of nutritious foods due to a lack of financial resources. Healthcare providers can use the two-item questionnaire that has been derived from the 18-item Household Food Security Survey Model and has been deemed successful in clinical settings at identifying those at risk of food insecurity.²⁸ Physicians should screen all patients for food insecurity, not just those with abnormal growth parameters or participation in public assistance programs, as food insecurity is often invisible.29 As previously mentioned, there is a greater burden of illness and other issues in food-insecure households and, therefore, these individuals may need more resources to effectively cope and receive adequate treatment.²²

Screening for food insecurity engages a patient-centered approach, yet there is no evidence that screening directly improves patient health.³⁰ Nevertheless, it can be expected that screening for food insecurity may lead to changes in clinical management. For instance, food-insecure patients, especially those coping with type 2 diabetes, have greater trouble adhering to nutritional and medical recommendations than food-secure individuals.³¹ In fact, when patients must choose between food and medication, they are predisposed to either hypoglycemia or hyperglycemia.^32–34 Once the healthcare provider identifies their patient as food insecure, they can offer and advocate for alternative services such as drug and disability benefits, generic versions of medications or mobility devices in addition to referring the patient to a dietitian, who may provide advice on dietary allowance and choosing sustainable foods.³⁵ Therefore, patient screening for food insecurity with a validated measure²⁸ may identify at-risk individuals and improve clinical management of the disease.³⁶

The relationship between food insecurity and poor health is believed to be bidirectional.²² Although food insecurity leads to poor health outcomes, poor health itself can increase one’s risk of becoming food insecure.^22,27 As healthcare professionals, physicians are distinctively positioned to identify individuals whose poor health may threaten their household food security and help them access appropriate resources.²² Individuals suffering from chronic illnesses have a harder time managing with limited funds as they are less likely to participate in labour-intensive approaches to finding affordable food.²² Healthcare professionals play an important role in developing clinical strategies to improve disease management, reduce the risk of becoming food insecure and alleviate the negative effects on other members of the household.²² Therefore, screening patients at risk of food insecurity may act as a preventative measure to stop vulnerable individuals and households from becoming food insecure.

Although patient screening for food insecurity allows physicians to identify individuals at risk of becoming food insecure, a substantial issue concerning patient screening is the shameful lack of available public assistance programs to which patients can be referred. Because there is a paucity of public policy interventions, the healthcare provider bears great responsibility to find relevant and nutritious resources for their food-insecure patients. Food banks and food-distribution centres like soup kitchens rely on volunteer labour and donations, are small-scale, geographically-fragmented, have limited resources and are not used by the majority of food-insecure Canadians.^37–39 These organizations struggle to reduce individual and household food insecurity as participants are often without basic resources like adequate income, stable and affordable housing and child care.⁴⁰ Therefore, an essential role of the healthcare provider is to advocate for the development of government nutritional assistance programs as well as the subsidization of nutrient-dense foods such as apples, cheese, carrots and broccoli.41 Likewise, Canadian Food Centres Canada⁴² can promote the collaboration between healthcare systems and community organizations to create community gardens, healthy-cooking programs, patient education and food prescriptions – discounts that can be redeemed on produce.^30,43 Canadian healthcare professionals will face significant issues when screening patients for food insecurity as the available services are limited, but they can act as influential and informed advocates of evidence-based methods to reduce food insecurity in Canada.

Another potential concern is that patient screening will not capture all food-insecure individuals because it relies on individuals accessing healthcare services as well as disclosing information regarding food security. Although physician appointments are covered through the Canada Health Act,⁴⁴ roughly 15% of Canadians reported they did not have a regular family physician.⁴⁵ However, it appears that food-insecure individuals are more likely to use healthcare services when compared to those who can afford food.^46,47 Moreover, patients may be reluctant to provide information on food insecurity for fear of losing custody of their children^11,48 and similarly, physicians may be uncomfortable engaging in a discussion.^49,50 To address this issue, healthcare professionals can undergo training⁵¹ and make prompts (posters and flyers) available in the waiting and exam rooms to reassure patients and encourage open discussion. Although patient screening may be uncomfortable for both the patient and the healthcare provider⁴⁹ and may leave several ill and food-insecure Canadians undetected, it is expected that many individuals will reveal issues with food security through repeated screening over time, which will allow healthcare providers to intervene and improve disease management in these patients.^30,36

Healthcare professionals play a crucial role in the disease and nutrition management and health promotion of Canadians. Although it is unknown whether screening for food insecurity improves health, patient screening is warranted because of its ability to improve clinical management in certain patients.³⁰ Patient screening for food insecurity should be trialed as a temporary strategy to improve disease management. Although flawed, it allows physicians to identify food-insecure patients, to potentially alter their course of treatment and to advocate for them in an intimate and professional way. It is essential that healthcare professionals advocate for effective monitoring of food insecurity at the population level to elucidate factors influencing susceptibility and inform the development and assessment of such policies.⁵² Finally, healthcare professionals are uniquely positioned to recognize food insecurity, intervene in a clinical setting and advocate for change in their communities.⁵³

References

Sriram, U. & Tarasuk, V. Changes in household food insecurity rates in Canadian metropolitan areas from 2007 to 2012. Can. J. Public Health Rev. Can. Sante Publique 106,e322-327 (2015).

Gundersen, C. & Ziliak, J. P. Food Insecurity And Health Outcomes. Health Aff. (Millwood) 34,1830–1839 (2015).

Martin, M. S., Maddocks, E., Chen, Y., Gilman, S. E. & Colman, I. Food insecurity and mental illness: disproportionate impacts in the context of perceived stress and social isolation. Public Health 132,86–91 (2016).

Jyoti, D. F., Frongillo, E. A. & Jones, S. J. Food Insecurity Affects School Children’s Academic Performance, Weight Gain, and Social Skills. J. Nutr. 135,2831–2839 (2005).

Statistics Canada. Household food insecurity, 2011-2012. (2015). Available at: http://www.statcan.gc.ca/pub/82-625-x/2013001/article/11889-eng.htm. (Accessed: 2nd December 2016)

Tarasuk, V., Mitchell, A. & Dachner, N. Household food insecurity in Canada, 2014.(2016).

Kirkpatrick, S. I. et al.Household Food Insecurity Is a Stronger Marker of Adequacy of Nutrient Intakes among Canadian Compared to American Youth and Adults. J. Nutr. 145,1596–1603 (2015).

Skalicky, A. et al.Child food insecurity and iron deficiency anemia in low-income infants and toddlers in the United States. Matern. Child Health J.10,177–185 (2006).

Whitaker, R. C., Phillips, S. M. & Orzol, S. M. Food Insecurity and the Risks of Depression and Anxiety in Mothers and Behavior Problems in their Preschool-Aged Children. Pediatrics 118,e859–e868 (2006).

Roustit, C., Hamelin, A.-M., Grillo, F., Martin, J. & Chauvin, P. Food insecurity: could school food supplementation help break cycles of intergenerational transmission of social inequalities? Pediatrics 126,1174–1181 (2010).

Hamelin, A.-M., A. M., Beaudry, M. & Habicht, J.-P., J. P. Characterization of household food insecurity in Québec: food and feelings. Soc. Sci. Med. 54,119–132 (2002).

Black, M. M. Integrated strategies needed to prevent iron deficiency and to promote early child development. J. Trace Elem. Med. Biol. Organ Soc. Miner. Trace Elem. GMS 26,120–123 (2012).

Dubois, L. et al.Household food insecurity and childhood overweight in Jamaica and Québec: a gender-based analysis. BMC Public Health 11,199 (2011).

Mangini, L. D., Hayward, M. D., Dong, Y. Q. & Forman, M. R. Household Food Insecurity is Associated with Childhood Asthma. J. Nutr. 145,2756–2764 (2015).

Kleinman, R. E. et al.Hunger in children in the United States: potential behavioral and emotional correlates. Pediatrics 101,E3 (1998).

Slopen, N., Fitzmaurice, G., Williams, D. R. & Gilman, S. E. Poverty, food insecurity, and the behavior for childhood internalizing and externalizing disorders. J. Am. Acad. Child Adolesc. Psychiatry 49,444–452 (2010).

Melchior, M. et al.Food insecurity and children’s mental health: a prospective birth cohort study. PloS One 7,e52615 (2012).

Shtasel-Gottlieb, Z., Palakshappa, D., Yang, F. & Goodman, E. The relationship between developmental assets and food security in adolescents from a low-income community. J. Adolesc. Health Off. Publ. Soc. Adolesc. Med. 56,215–222 (2015).

McIntyre, L., Williams, J. V. A., Lavorato, D. H. & Patten, S. Depression and suicide ideation in late adolescence and early adulthood are an outcome of child hunger. J. Affect. Disord. 150,123–129 (2013).

Garner, A. S., Shonkoff, J. P., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care & Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics 129,e224-231 (2012).

Kirkpatrick, S. I., McIntyre, L. & Potestio, M. L. Child Hunger and Long-term Adverse Consequences for Health. Arch. Pediatr. Adolesc. Med. 164,754–762 (2010).

Tarasuk, V., Mitchell, A., McLaren, L. & McIntyre, L. Chronic Physical and Mental Health Conditions among Adults May Increase Vulnerability to Household Food Insecurity. J. Nutr. 143,1785–1793 (2013).

To, Q. G., Frongillo, E. A., Gallegos, D. & Moore, J. B. Household food insecurity is associated with less physical activity among children and adults in the U.S. population. J. Nutr. 144,1797–1802 (2014).

Fram, M. S., Ritchie, L. D., Rosen, N. & Frongillo, E. A. Child experience of food insecurity is associated with child diet and physical activity. J. Nutr. 145,499–504 (2015).

Leung, C. W., Epel, E. S., Ritchie, L. D., Crawford, P. B. & Laraia, B. A. Food insecurity is inversely associated with diet quality of lower-income adults. J. Acad. Nutr. Diet. 114,1943–1953.e2 (2014).

Huet, C., Rosol, R. & Egeland, G. M. The prevalence of food insecurity is high and the diet quality poor in Inuit communities. J. Nutr. 142,541–547 (2012).

Seligman, H. K. & Schillinger, D. Hunger and Socioeconomic Disparities in Chronic Disease. N. Engl. J. Med. 363,6–9 (2010).

Hager, E. R. et al.Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics 126,e26-32 (2010).

Beck, A. F. et al.Forging a Pediatric Primary Care–Community Partnership to Support Food-Insecure Families.Pediatrics 134,e564–e571 (2014).

Berkowitz, S. A. & Fabreau, G. E. Food insecurity: What is the clinician’s role? CMAJ Can. Med. Assoc. J. 187,1031 (2015).

Seligman, H. K., Jacobs, E. A., López, A., Tschann, J. & Fernandez, A. Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes Care 35,233–238 (2012).

Seligman, H. K., Davis, T. C., Schillinger, D. & Wolf, M. S. Food Insecurity is Associated with Hypoglycemia and Poor Diabetes Self-Management in a Low-Income Sample with Diabetes. J. Health Care Poor Underserved 21,1227 (2010).

Berkowitz, S. A., Gao, X. & Tucker, K. L. Food-insecure dietary patterns are associated with poor longitudinal glycemic control in diabetes: results from the Boston Puerto Rican Health study. Diabetes Care 37,2587–2592 (2014).

Silverman, J. et al.The Relationship Between Food Insecurity and Depression, Diabetes Distress and Medication Adherence Among Low-Income Patients with Poorly-Controlled Diabetes.J. Gen. Intern. Med. 30,1476–1480 (2015).

Messer, E. & Ross, E. M. Talking to patients about food insecurity. Nutr. Clin. Care Off. Publ. Tufts Univ. 5,168–181 (2002).

Galesloot, S., McIntyre, L., Fenton, T. & Tyminski, S. Food insecurity in Canadian adults receiving diabetes care. Can. J. Diet. Pract. Res. Publ. Dietit. Can. Rev. Can. Prat. Rech. En Diet. Une Publ. Diet. Can. 73,e261-266 (2012).

Tarasuk, V. & Eakin, J. M. Charitable food assistance as symbolic gesture: an ethnographic study of food banks in Ontario. Soc. Sci. Med. 198256,1505–1515 (2003).

Kirkpatrick, S. I. & Tarasuk, V. Food insecurity and participation in community food programs among low-income Toronto families. Can. J. Public Health Rev. Can. Sante Publique 100,135–139 (2009).

Tarasuk, V. et al.A survey of food bank operations in five Canadian cities. BMC Public Health 14,1234 (2014).

Power, E. & Dietitians of Canada. Individual and household food insecurity in Canada: position of Dietitians of Canada. Can. J. Diet. Pract. Res. Publ. Dietit. Can. Rev. Can. Prat. Rech. En Diet. Une Publ. Diet. Can. 66,43–46 (2005).

Ke, J. & Ford-Jones, E. L. Food insecurity and hunger: A review of the effects on children’s health and behaviour. Paediatr. Child Health 20,89–91 (2015).

Community Food Centres Canada. The Pod Knowledge Exchange. (2015). Available at: http://thepod.cfccanada.ca/. (Accessed: 15th December 2016)

Goddu, A. P., Roberson, T. S., Raffel, K. E., Chin, M. H. & Peek, M. E. Food Rx: a community-university partnership to prescribe healthy eating on the South Side of Chicago. J. Prev. Interv. Community 43,148–162 (2015).

Government of Canada. Canada’s health care system. (2016). Available at: http://healthycanadians.gc.ca/health-system-systeme-sante/system-systeme/about-apropos-eng.php. (Accessed: 15th December 2016)

Statistics Canada. Access to a regular medical doctor, 2012. (2015). Available at: http://www.statcan.gc.ca/pub/82-625-x/2013001/article/11832-eng.htm. (Accessed: 2nd December 2016)

Nelson, K., Cunningham, W., Andersen, R., Harrison, G. & Gelberg, L. Is food insufficiency associated with health status and health care utilization among adults with diabetes? J. Gen. Intern. Med. 16,404–411 (2001).

Tarasuk, V. et al.Association between household food insecurity and annual health care costs. CMAJ Can. Med. Assoc. J. 187,E429 (2015).

López, A. & Seligman, H. K. Clinical Management of Food-Insecure Individuals With Diabetes. Diabetes Spectr. 25,14–18 (2012).

Barnidge, E., LaBarge, G., Krupsky, K. & Arthur, J. Screening for Food Insecurity in Pediatric Clinical Settings: Opportunities and Barriers. J. Community Health 1–7 (2016). doi:10.1007/s10900-016-0229-z

Hoisington, A. T., Braverman, M. T., Hargunani, D. E., Adams, E. J. & Alto, C. L. Health care providers’ attention to food insecurity in households with children. Prev. Med. 55,219–222 (2012).

Burkhardt, M. C., Beck, A. F., Conway, P. H., Kahn, R. S. & Klein, M. D. Enhancing Accurate Identification of Food Insecurity Using Quality-Improvement Techniques. Pediatrics 129,e504–e510 (2012).

Kirkpatrick, S. I. & Tarasuk, V. Food insecurity in Canada: considerations for monitoring. Can. J. Public Health Rev. Can. Sante Publique 99,324–327 (2008).

Pediatrics, C. on C. & Nutrition, C. O. Promoting Food Security for All Children. Pediatricspeds.2015-3301 (2015). doi:10.1542/peds.2015-3301