Providing Food Security From Across the Pharmacy Counter

Commentary
Article

Pharmacists can play a critical role in addressing food insecurity in their communities, with a variety of tools at their disposal.

Health equity is described as the state in which everyone has a fair and just opportunity to attain their highest level of health, well-being, and quality of life. Despite pharmacological advances, patients continue to face poor health outcomes related to chronic health conditions because of wide disparities in conditions. These social determinants of health (SDOH) include key determinants such as housing, nutrition, transportation, social/economic mobility, and education.

An apple on a dry cracked desert soil.

Image credit: sulit.photos | stock.adobe.com

About the Author

Heather J. Rhodes-Pope, PharmD, MBA, BCPS, is a clinical pharmacy coordinator and PGY1 pharmacy residency director at Womack Army Medical Center; and a health and well-being coach trained at Duke Health & Well-Being.

County Health Rankings (CHR) data from across the US shows that socioeconomic drivers account for nearly half (47%) of health outcomes, with the remaining factors related to behaviors (34%), clinical care (16%), and the physical environment (3%).1 Pharmacists’ mindfulness of SDOH in patient care can promote the necessary resources to achieve optimal health outcomes.

The United States Department of Agriculture (USDA) defines food insecurity as a household-level economic and social condition of limited or uncertain access to food; it is further differentiated into categories: high, marginal, low, and very low food security (See Table A). Expanding on this definition, nutrition security is defined as consistent and equitable access to healthy, safe, affordable foods essential to optimal health and well-being.2

A USDA Economic Report on 2022 data shows that nearly 13% of US households (roughly 17 million homes) are affected by food insecurity. Homes with children, homes with children under age 6, homes with children headed by a single female, women living alone, homes with Black, non-Hispanic, and Hispanic persons, households with incomes below defined poverty thresholds, and homes in principal cities and nonmetropolitan areas are disproportionately affected by food insecurity compared to the national average.3

Food Security

USDA Definition

High

Households had no problems, or anxiety about, consistently accessing adequate food

Marginal

Households had problems at times, or anxiety about, accessing adequate food, but the quality, variety, and quantity of their food intake were not substantially reduced

Low

Reports of reduced quality, variety, or desirability of diet. Little or no indication of reduced food intake

Very Low

Reports of multiple indications of disrupted eating patterns and reduced food intake

The consumption of nutrient-dense foods is overshadowed by foods high in calories yet low in nutritional value. Most of the US population fail to consume recommended daily fruits and vegetables, with only 20% consuming at least 2 cups of fruit per day and only 10% consuming at least 2.5 cups of vegetables per day.4

Food insecurity negatively impacts overall health and well-being resulting in poor health outcomes related to type 2 diabetes mellitus, cardiovascular health, and mental health. From a pathophysiology perspective, food insecurity increases insulin resistance along with biomarkers from inflammation (ie, hsCRP) and stress (ie, cortisol). Studies among patients with type 2 diabetes mellitus show an increased number of emergency department visits and hospitalizations and negative correlations with A1c levels, self-care practices, diabetes-related distress, and depression.5,6 Food insecurity has been shown to have an independent effect on cardiovascular-related mortality, with studies showing a 58% higher risk of mortality compared to individuals in food secure households.7 Studies show an increased risk for depression, anxiety, and sleep disorders among those affected by food insecurity.8

Federal nutrition assistance programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Supplemental Nutrition Assistance Program (SNAP), and the National School Lunch Program from the US Department of Agriculture provide access to foods for vulnerable populations. WIC serves the nutritional needs of low-income, vulnerable populations that includes those pregnant, breastfeeding, and non-breastfeeding postpartum women, infants, and children younger than age 5. This program is designed to offer supplemental foods, health care referrals, and nutrition education.

SNAP provides monthly benefits to eligible low-income households to purchase food items at SNAP-authorized retailers.3 The National School Lunch Program serves students at public and non-profit private schools and residential childcare institutions to receive breakfast and lunch for free, at reduced cost, or full price based on household income. The program has expanded serves to include summer meals for eligible participants meeting needs throughout the year.

Commonly known local community resources often include food pantries, banks, or soup kitchens. Urban agriculture and farms provide equitable food resources, nutrition education, and improve agricultural literacy within cities. Examples of non-profit (501(c)(3)) urban programs include community garden organizations, garden allotment organizations, backyard harvest organizations, and organizations that promote youth agricultural literacy or train people to cultivate their own gardens.9

One example is Orange Home Grown, a small urban education farm just on the outskirts of Anaheim in the city of Orange, California. This 7000 square foot farm is nestled between a parking deck and Chapman University where they provide scholarships for students studying agriculture, food science, sustainability, and other related fields. Orange Home Grown produces food for the local farmers’ market serving more than 2000 weekly shoppers. Megan Penn, the executive director at Orange Home Grown, shared that they also have a seed lending library and a partnership with the local high school FFA students to further promote food security, education, and community resources.

Despite federal program assistance and community resources, food and nutrition insecurity abound. Hospital-based food pantries especially are on the rise and positioned to provide a convenient option for patients needing both health and social services in one centralized location. An Ohio-based Food as Medicine Clinic, within the MetroHealth System, provided 79 patients with expanded access to nutrient-dense foods through their hospital-based food pantry.

Survey results at both 3 and 6 months indicate that self-reported eating habits showed increased consumption of fruits/vegetables, increased variety of vegetables per day, and decreased fast food consumption. Trained diet technicians and personal shopping assistants provided medically tailored choices, recipes, and assistance in selecting appropriate quantities. Transportation vouchers were also given to patients.10

A smaller study enrolled 30 patients to a hospital-based food pantry program offering medically tailored food options and a teaching kitchen for free cooking classes at Boston Medical Center. The patients acknowledged a greater level of trust in the staff, satisfaction with the nutritional quality of food options, and less stigmatism than in the community setting. Their findings suggests that there remain opportunities to improve food insecurity screening and referral processes, nutritional guidelines for food donations, and expanded nutrition education.11

Longer studies are needed with a greater number of patients to establish health outcomes benefits (ie, blood pressure, lipids, A1C, BMI, etc) and reduced health care utilization (ie, hospitalizations and ED visits). Standardizing food pantry donations in health care settings may improve the availability of nutritionally dense food options and to balance against access to unhealthy choices. Further research is needed to explore patient engagement in these programs. Studies among hospital-based food pantries in rural settings may explore the impact to greater populations.

At the frontlines of health care, pharmacists build long-lasting, trusting relationships with patients. Screening for food insecurity helps pharmacists identify opportunities to advance equity. Formal screening tools include the 2-item Hunger Vital SignTM and the USDA 18-item questionnaire, which is considered to be the gold-standard. Other modified tools exist including 6-item and 10-item questionnaires.12

The Hunger Vital SignTM

1) Within the past 12 months we worried whether our food would run out before we got money to buy more.

2) Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.

Screeners ask if either of the above states are often true, sometimes true, or never true to help identify those at risk for food insecurity.

Pharmacists within community settings should recognize opportunities for sharing medication and non-medication related resources when gaps in medication fill history are identified. A National Health Interview Survey shows that many participants reporting cost-related medication underuse are affected by food insecurities. Incorporating an additional service of sharing local resources to access nutritious foods in conjunction with cost-savings programs such as medication-assistance programs, and medication discount coupons may help provide patients a holistic and equitable approach to health care while at the pharmacy.13

Pharmacists may volunteer within their communities to raise awareness of local resources and collaborate with other health care and community members. Local food policy councils create opportunities for partnerships among a wide range of thought leaders.

One example of a local food policy council within North Carolina is with Fort Liberty (an army installation) and Cumberland County. The council includes 15 members who represent the local military post, the county, health care, local farming/agriculture, education, and non-government community members at-large. Their initiatives create broad efforts to advance health equity and reduce food and nutrition insecurities (Table B).14

Category

Council Initiatives

Culturally Inclusive Foods

Increase access to healthy, nutritious, and culturally inclusive foods in both Fort Liberty and Cumberland County by identifying and recommending policy changes to Fort Liberty and Cumberland County leadership

Health, Equity, and Sustainability

Incorporate health, equity, and sustainability considerations in policies, processes, and decisions as it relates to food insecurity

Food Insecurity

Decrease the current number of adults and children facing food insecurity in the Cumberland County

Food System Workers

Communicate with various food system stakeholders for their expertise and build a better sense of cohesion amongst food system workers

Community Collaboration

Collaborate with Community Food Strategies to network with other existing Food Policy Councils in the Southeast Region of North Carolina

Local Resources

Explore ways to conserve local resources such as plants and soil, water, air quality, farming and agricultural land, local livestock, and capital

References
1. Social Determinants of Health. Accessed November 20, 2023. https://www.cdc.gov/about/sdoh/index.html.
2. U.S. Department of Agriculture, Economic Research Service. (n.d.). Food Security in the U.S. Accessed December 4, 2023, from https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/measurement/
3. Rabbitt, M.P., Hales, L.J., Burke, M.P., & Coleman-Jensen, A. (2023). Household Food Security in the United States in 2022 (Report No. ERR-325), U.S. Department of Agriculture, Economic Research Service.
4. The USDA 2020-2025 Dietary Guidelines. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf
5. Schroeder EB, Zeng C, Sterrett AT, Kimpo TK, Paolino AR, Steiner JF. The longitudinal relationship between food insecurityin older adults with diabetes and emergency department visits, hospitalizations, hemoglobin A1c, and medication adherence. J Diabetes Complicat. 2019;33(4):289–95.
6. Walker RJ, Campbell JA, Egede LE. Differential impact of food insecurity, distress, and stress on self-care behaviors and glycemic control using path analysis. J Gen Intern Med. 2019;34(12):2779–85.
7. Banerjee S, Radak T, Khubchandani J, Dunn P. Food insecurity and mortality in American adults: results from the NHANES-linked mortality study. Health Promot Pract. 2021;22(2):204–14.
8. Arenas DJ, Thomas A, Wang J, DeLisser HM. A systematic review and meta-analysis of depression, anxiety, and sleep disorders in US adults with food insecurity. J Gen Intern Med. 2019;34(12):2874–82.
9. Urban Ag Law. Accessed December 1, 2023. https://urbanaglaw.org/non-profit-urban-ag/
10. Hu D, Cherian A, Chagin K, et al. Food as Medicine Clinic: Early Results and Lessons Learned. Cureus. 14(11):e31912.
11. Greenthal E, Jia J, Poblacion A, et al. Patient experiences and provider perspectives on a hospital-based food pantry: a mixed methods evaluation study. Public Health Nutrition. 2019;22 (17), 3261-3269.
12. Survey Tools. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/survey-tools/. Accessed November 24, 2023.
13. Berkowitz SA, Seligman HK, Choudhry NK. Treat or eat: food insecurity, cost-related medication underuse, and unmet needs. Am J Med. 2014;127(4):303–10 e3.
14. Cumberland County Food Policy Council. Accessed December 5, 2023. https://www.co.cumberland.nc.us/departments/public-health-group/public-health/community-services/food-policy-council
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