Issue: November 2020
Source: Healio Interview
Disclosures: Cavagnaro, Lupe, Palakshappa, Singh and Weiser report no relevant financial disclosures.
November 20, 2020
8 min read
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Food insecurity: A growing pain in the United States

Issue: November 2020
Source: Healio Interview
Disclosures: Cavagnaro, Lupe, Palakshappa, Singh and Weiser report no relevant financial disclosures.
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Limited or uncertain access to nutritionally adequate food is prevalent in about 11.1% of the population in the United States, according to a study published in the Journal of Clinical Gastroenterology and Hepatology.

Siddarth Singh, MD, gastroenterologist and assistant professor of medicine at University of California, San Diego Health, and colleagues noted factors such as lack of social networks or social cohesion can lead to adverse health outcomes. They said one in eight patients with inflammatory bowel disease are food insecure and lack social support.

Stacy Cavagnaro, RD, a registered dietician for the Inflammatory Bowel Disease Medical Home at Cleveland Clinic, said food insecurity can lead to a higher risk for developing malnutrition.
Stacy Cavagnaro, RD, a registered dietician for the Inflammatory Bowel Disease Medical Home at Cleveland Clinic, said food insecurity can lead to a higher risk for developing malnutrition.

Source: Cleveland Clinic.

“Food insecurity is surprisingly pervasive, with one in eight Americans being food insecure and it extends to patients with IBD,” Singh told Healio Gastroenterology. “IBD can be an expensive disease with significant financial toxicity and patients may have to choose between healthy food and paying bills and costly medications. Conversely, there is increasing evidence on the role of processed food and unhealthy eating habits, more likely to be consumed by people who are food insecure, in causing IBD.”

Patients who were food insecure were seven times more likely to experience financial hardship, experience financial distress and experience cost-related medication non-adherence, according to Singh and colleagues.

Healio Gastroenterology spoke with experts on the lack of research on food insecurity in the United States, the current impact of COVID-19 and what needs to be done to decrease it.

Research on food insecurity in IBD lacking

In an interview with Healio Gastroenterology, Stacy Cavagnaro, RD, a registered dietitian for the Inflammatory Bowel Disease Medical Home at Cleveland Clinic, said studies have been performed that looked at food insecurity relating to obesity, diabetes, hypertension and metabolic syndrome; however, there has not been a lot of research done on food security as it relates to IBD, autoimmune disease, liver disease, cancer, etc.

“Researchers may want to look at the ability to obtain food for patients on specialized diets (costs, accessibility, social constraints, etc) for conditions such as IBD, gastroparesis, celiac disease, IBS, epilepsy, heart disease and diabetes,” she said.

Stephen Lupe, PsyD
Stephen Lupe

Stephen Lupe, PsyD, psychologist for Inflammatory Bowel Disease Medical Home, Digestive Disease & Surgery Institute at Cleveland Clinic, said there hasn’t been a good explanation for why food insecurity is frequently seen in IBD populations.

“There hasn’t been a lot of research done in food insecurity in IBD populations and there really should be because nutrition is an important aspect of caring for patients who have been diagnosed with an IBD condition,” Lupe said. “We’re not really talking about it. It is something that needs to change. We need to look at IBD as a multifactorial disease.”

He said there was a study that reported approximately 69% of patients receive little to no information about diet from their providers.

Siddarth Singh, MD
Siddarth Singh

“Food insecurity is pervasive and can pose unique challenges to patients with GI conditions,” Singh said. “Patients with several GI diseases like irritable bowel syndrome, IBD, celiac disease, cirrhosis may need to significantly modify their diet to alleviate symptoms and manage disease.”

Singh said diet modifications such as a gluten free diet, avoidance of readily available processed food and switching to fruits and vegetables may be expensive so food insecure patients have a hard time following dietary recommendations and this may exacerbate symptoms and quality of life may be worsened.

“Food pantries may not carry foods for special diets. In one example, I worked with a patient who had concurrent IBD and celiac disease,” Cavagnaro said. “Due to a number of chronic conditions, they were disabled. There was one food pantry in their city that carried gluten-free products, which they could access with a doctor’s note. The problem — this pantry was not near their home, and they did not have reliable transportation, which increased the stress they felt regarding their ability to obtain food. Another problem is food deserts, or areas that do not have a grocery store within close proximity. Without reliable transportation, many of these patients may rely on corner stores or fast food, making it difficult to follow a strict diet to help manage their condition.”

Cavagnaro said worsening of GI symptoms lead to malabsorption of nutrients, vitamin and mineral deficiencies, and weight loss. This along, with food insecurity, can lead to a higher risk for developing malnutrition. Malnutrition is correlated with increased risk for disease complications, surgical complications, and increased length of hospital stay.

“As you can see, there is a cycle with food insecurity, stress, nutrition and disease activity,” Cavagnaro said.

Food insecurity drives mental health

Food insecurity contributes to nonadherence to treatment and care recommendations, Sheri Weiser, MD, professor of medicine in the division of HIV, infectious diseases and global medicine at the University of California, San Francisco, said in an interview with Healio Gastroenterology. Food insecure people tend to have a difficult time having a balanced diet. They often have little choice by to eat less expensive proinflammatory foods such as sugars, fat and processed food that create more inflammation compared with fruits and vegetables, healthy fats and protein, according to Weiser.

Sheri Weiser, MD
Sheri Weiser

“If people don’t have enough food to eat, and they can’t take their medications on an empty stomach because of the side effects, they’re going to be nonadherent with their medications,” Weiser said.

“There’s a large body of literature showing that food insecurity is a key driver of many different mental health conditions,” Weiser added. “Food insecurity has been associated with stress, depression, anxiety, post-traumatic stress disorder and other mental health conditions. Poor mental health can have many negative effects that would be relevant to people with IBD and other conditions.” For example, poor mental health can interfere with adherence to treatment and care and be a driver for inflammation, she said.

Deepak Palakshappa, MD
Deepak Palakshappa

Deepak Palakshappa, MD, is an assistant professor and practices general internal medicine and pediatrics, at Wake Forest Baptist Health in North Carolina, told Healio Gastroenterology, that patients with GI conditions who have food insecurity are often faced with competing demands. Therefore, patients with food insecurity may skip medications or delay preventive care, which leads to worsening of underlying health conditions, Palakshappa said.

Approximately 60% of individuals who are food insecure worldwide are women and girls because many have no choice but to defer their education or are not given opportunity for a proper education and training, according to Weiser. As a result, they may not have financial independence, which can contribute to food insecurity.

Poverty may also be a driver for food insecurity, she said.

“It’s really discrimination,” Weiser said. “There’s certainly a large disparity in terms of food insecurity and we find racial and ethnic minority groups being overrepresented among the food insecure.” Violence may also be a driver for food insecurity.

Cavagnaro reported food desserts may impact food insecurity. She also mentioned access to health care services, reliable transportation, social support and socioeconomic status.

COVID-19 exacerbated food insecurity

The COVID-19 pandemic has been increasing food insecurity. Food insecurity can worsen health among people who have COVID-19 because it may impact conditions such as diabetes, asthma and lung disease, according to Weiser.

Palakshappa said it is yet to be determined how COVID-19 has affected food insecurity; however, households with food insecurity will increase due to the pandemic.

“Prior to COVID-19, 11.1% of the U.S. population — over 35 million people — were estimated to be food insecure,” Palakshappa said. “Feeding America estimated this will rise by anywhere from 9.9 million to 17 million due to COVID.”

The COVID Impact Survey reported that by April 2020 the 11.1% of the food insecure population increased by 22.7%. Rates of household food insecurity doubled. According to the survey, food insecurity in households with children under 18 years increased by approximately 130% from 2018 to now. As of late April 2020, 34.5% of households with a child 18 years or younger were food insecure.

“The huge rise in food insecurity is not going to go away overnight, we’re going to be here for a long time,” Weiser said.

“With increasing unemployment and poverty due to COVID-19, the burden of food insecurity is increasing,” Singh said. “Unfortunately, food insecurity also increases the risk of chronic medical diseases like obesity, diabetes, hypertension, etc, which have been associated with worse outcomes in patients with COVID-19.”

Many people who are food insecure are scared to seek food resources such as food pantries, in fear of going to the site and contracting COVID-19, Palakshappa said.

“COVID-19 is likely exacerbating all problems,” Lupe said. “It’ll be interesting to see what data comes out of the pandemic in the future when we look at the effect of COVID-19.”

Lupe noted minority communities have been hit hardest by the virus because they do not often have access to health care or the ability to work from home. This may make it difficult for a family to get food for their household or may increase insecurity in the food available.

Organizations like Safe Hands and ABV held an event, the Safe Hands Artist Series on Sept. 16, 2020, to raise funds for those who were food insecure due to the pandemic. Three artists sold their artwork with 50% of the profits going to them, and 50% would be used to fight world hunger through a Safe Hands partnership with Rise Against Hunger, according to a Safe Hands press release. The company currently donates 25% of its proceeds to Rise Against Hunger.

What needs to be done

“Food insecurity is deeply interconnected to poverty and unemployment/under-employment, hence, it requires major policy changes to decrease food injustice,” Singh said. “Some measures would include minimum wage, school meal programs, decrease food wastage, supporting and strengthening food banks.”

Weiser noted food insecurity needs to be handled in a multi-tiered approach. Addressing food insecurity would help individuals stop engaging in sex for food and therefore prevent HIV and STD. It may also prevent prediabetes and diabetes in young people.

Palakshappa said causes of food insecurity are complex. It is a downstream effect of problems such as poverty, racism, income inequality and access to food.

Further, Palakshappa said public programs such as Supplemental Nutrition Assistance Program, or SNAP, should be strengthened to offer cash benefits for people to purchase food. Other changes that may help end food insecurity include creating jobs, increase wages for low-income work and ensure families have easy access to low-cost healthy food.

Lupe said finding a way to end food insecurity and increase health is the million-dollar question.

“There haven’t been viable suggestions for this very complicated issue,” Lupe said. “Do we make it part of health care where we treat food insecurity as a major cause for health conditions? It is very difficult to treat patients with chronic health conditions and when they are also underinsured.”

He stated that these problems are complex and the data suggest that diet influences the course of a chronic illness. The medical community has not identified a universal way to intervene in this connection and there needs to be an effort to treat all factors that contribute to chronic disease.

Palakshappa said there are studies that look at the implementation of strategies to screen and address food insecurity in clinical settings. Clinicians may use validated questionnaires to screen patients for food insecurity. For those who are food insecure, clinicians can help aid them in finding resources such as food pantries or SNAP and consider the best treatment for patients, he said.

“Research has found that addressing food insecurity and other unmet social needs in clinical care settings can improve the resources patients receive and future studies will need to determine if this ultimately improves health outcomes,” Palakshappa said.

Lupe said researchers need to look further at how many people with a known diagnosis of IBD are food insecure. To complicate matters, patients who are food insecure who may not even have received a diagnosis of IBD if they do not have access to care, he said.

Those patients are hard to identify if they are not coming in to see a physician,” Lupe said.

Lupe suggested it is hard for patients to receive treatment for their conditions without health care insurance. He said researchers should further look at the percentage of patients identified with IBD who are food insecure, and then the data on diet and other aspects of food insecurity should be reviewed. These factors need to be studied to determine the impact on the course and possible treatment options for patients diagnosed with IBD.

“This is an understudied topic,” Lupe said. “There is not a lot of data on food insecurity in the IBD populations. We need to look at people as influenced by a multitude of factors including stress, diet and genetics. We need to look at people diagnosed with chronic medical conditions and ensure these people are getting adequate nutrition and getting the food they need.”