Association between household food insecurity and annual health care costs

Examining risk factors for cardiovascular disease among food bank members in Vancouver

Food banks provide supplemental food to low-income households, yet little is known about the cardiovascular health of food banks members. This study therefore described cardiovascular disease (CVD) risk factors among food bank members and explored associations between food insecurity and CVD risk.

Adults ≥18 years (n = 77) from three food bank sites in metro Vancouver, British Columbia completed surveys and physical assessments examining a range of socio-demographic variables and CVD risk factors. A composite measure of myocardial infarction (MI) risk called the INTERHEART score was assessed and household food insecurity was measured using the Household Food Security Survey Module. Regression models were used to explore associations between food insecurity and CVD risk measures, including the INTERHEART score.

Ninety-seven percent of food bank members reported experiencing food insecurity, 65% were current smokers, 53% reported either chronic or several periods of stress in the past year, 55% reported low physical activity levels and 80% reported consuming fewer than five servings of fruit and vegetables daily. Prevalence of self-reported diabetes and hypertension were 13% and 29% respectively. Fifty-two percent of the sample were at high risk of non-fatal MI. No statistically significant associations were found between increased severity of food insecurity and CVD risk factors among this sample where both severe food insecurity and high CVD risks were prevalent.

Food bank members were at elevated risk for CVD compared with the general population. Strategies are needed to reduce prevalence of food insecurity and CVD risk factors, both of which disproportionately affected food bank members.

Food Insecurity and Health Care Expenditures in the United States, 2011-2013

OBJECTIVE

To determine whether food insecurity, limited or uncertain food access owing to cost, is associated with greater health care expenditures.

DATA SOURCE/STUDY SETTING

Nationally representative sample of the civilian noninstitutionalized population of the United States (2011 National Health Interview Survey [NHIS] linked to 2012-2013 Medication Expenditure Panel Survey [MEPS]).

STUDY DESIGN

Longitudinal retrospective cohort.

DATA COLLECTION/EXTRACTION METHODS

A total of 16,663 individuals underwent assessment of food insecurity, using the 10-item adult 30-day food security module, in the 2011 NHIS. Their total health care expenditures in 2012 and 2013 were recorded in MEPS. Expenditure data were analyzed using zero-inflated negative binomial regression and adjusted for age, gender, race/ethnicity, education, income, insurance, and residence area.

PRINCIPAL FINDINGS

Fourteen percent of individuals reported food insecurity, representing 41,616,255 Americans. Mean annualized total expenditures were $4,113 (standard error $115); 9.2 percent of all individuals had no health care expenditures. In multivariable analyses, those with food insecurity had significantly greater estimated mean annualized health care expenditures ($6,072 vs. $4,208, p < .0001), an extra $1,863 in health care expenditure per year, or $77.5 billion in additional health care expenditure annually.

CONCLUSIONS

Food insecurity was associated with greater subsequent health care expenditures. Future studies should determine whether food insecurity interventions can improve health and reduce health care costs.

The Ontario Food and Nutrition Strategy: identifying indicators of food access and food literacy for early monitoring of the food environment

INTRODUCTION

To address challenges Canadians face within their food environments, a comprehensive, multistakeholder, intergovernmental approach to policy development is essential. Food environment indicators are needed to assess population status and change. The Ontario Food and Nutrition Strategy (OFNS) integrates the food, agriculture and nutrition sectors, and aims to improve the health of Ontarians through actions that promote healthy food systems and environments. This report describes the process of identifying indicators for 11 OFNS action areas in two strategic directions (SDs): Healthy Food Access, and Food Literacy and Skills.

METHODS

The OFNS Indicators Advisory Group used a five-step process to select indicators: (1) potential indicators from national and provincial data sources were identified; (2) indicators were organized by SD, action area and data type; (3) selection criteria were identified, pilot tested and finalized; (4) final criteria were applied to refine the indicator list; and (5) indicators were prioritized after reapplication of selection criteria.

RESULTS

Sixty-nine potential indicators were initially identified; however, many were individual-level rather than system-level measures. After final application of the selection criteria, one individual-level indicator and six system-level indicators were prioritized in five action areas; for six of the action areas, no indicators were available.

CONCLUSION

Data limitations suggest that available data may not measure important aspects of the food environment, highlighting the need for action and resources to improve system-level indicators and support monitoring of the food environment and health in Ontario and across Canada.

Political rhetoric from Canada can inform healthy public policy argumentation

Household food insecurity (HFI), insufficient income to obtain adequate food, is a growing problem in Canada and other Organisation of economic cooperation and development (OECD) countries. Government political orientations impact health policies and outcomes. We critically examined Canadian political rhetoric around HFI from 1995 to 2012 as a means to support effective healthy public policy argumentation. We analysed a data set comprised of Hansard extracts on HFI from the legislative debates of the Canadian federal and three provincial governments, using thematic coding guided by interpretivist theories of policy. Extracts were examined for content, jurisdiction, the political affiliation of the legislator speaking and governing status. Members of non-governing, or 'opposition' parties, dominated the rhetoric. A central hunger-as-poverty theme was used by legislators across the political spectrum, both in government and in opposition. Legislators differed in terms of policy approach around how income should flow to citizens facing HFI: income intervention on the left, pragmatism in the centre, reliance on markets on the right. This analysis is a case-example from Canada and caution must be exercised in terms of the generalizability of findings across jurisdictions. Despite this limitation, our findings can help healthy public policy advocates in designing and communicating HFI policy interventions in OECD countries with a similar left-right spectrum. First, even with a divisive health policy issue such as actions to address HFI, core themes around poverty are widely understood. Secondly, the non-polarizing centrist, pragmatist, approach may be strategically valuable. Thirdly, it is important to treat the rhetoric of opposition members differently from that of government members.

Prevalence and determinants of food insecurity in migrant Sub-Saharan African and Caribbean households in Ottawa, Canada

Purpose

Food insecurity (FI) is an important social determinant of health and is linked with higher health care costs. There is a high prevalence of FI among recent migrant households in Canada. The purpose of this paper is to evaluate the prevalence of FI in Sub-Saharan African and Caribbean migrants in Ottawa, and to explore determinants of FI in that population.

Design/methodology/approach

A cross-sectional study was conducted among 190 mothers born in Sub-Saharan Africa or the Caribbean living in Ottawa and having a child between 6 and 12 years old. Health Canada’s Household Food Security Survey Module was used to evaluate participants’ food security in the past 12 months. χ2 tests and multivariate logistic regression analyses were used to measure determinants of FI (n=182).

Findings

A very high rate of FI (45.1 percent) was found among participants. When numerous determinants of FI were included in a multivariate model, household FI was associated with Caribbean origin, low education attainment, lone motherhood, living in Canada for five years or less and reliance on social assistance.

Originality/value

These findings highlight the need for FI to be explicitly addressed in migrant integration strategies in order to improve their financial power to purchase sufficient, nutritious and culturally acceptable foods. Enhancing migrants’ access to affordable child care and well-paid jobs, improving social assistance programs and providing more affordable subsidized housing programs could be beneficial.

Food insecurity and healthcare decision making among mobile food pantry clients in Tampa Bay

This article examines the relationship between food insecurity and health-care decision-making among mobile food pantry clients in Tampa Bay, Florida. Results show a high rate of food insecurity, high stress levels, and chronic health conditions among mobile pantry clients, many of whom are long-term users of food pantry services. The fruits and vegetables supplied by the pantry allow clients to manage chronic health conditions and mitigate some of the financial burden of health-care costs. Research was conducted in cooperation with the Anthropology Department at the University of South Florida, Feeding Tampa Bay, and WellCare .

Interventions to address household food insecurity in high-income countries

Household food insecurity is a serious public health concern in high-income countries. Canada and the USA regularly monitor household food insecurity, while in other countries, such as the UK, it has been the rapid rise of food bank usage that has drawn increased attention to this longstanding, but largely overlooked, problem. This review evaluates evidence on interventions intended to reduce household food insecurity in high-income countries. Research on social protection interventions suggests both cash transfers and food subsidies (e.g. the US Supplement Nutrition and Assistance Programme) reduce household food insecurity. In contrast, research on community-level interventions, such as food banks and other food programmes, suggests limited impacts. Although food banks have become a common intervention for food insecurity in high-income countries, evidence suggests their reliance on donations of volunteer time and food make them inevitably limited in the assistance they are able to provide. The stigma people feel using food banks may also make them untenable. Alternatives to, or enhanced, food banks such as community shops or community kitchens, have become common, but evidence also suggests they may be limited in effectiveness if they do not reach people experiencing food insecurity. This review highlights the difficulty of trying to address household food insecurity with community-based food interventions when solutions likely lie upstream in social protection policies.

Prioritization of the essentials in the spending patterns of Canadian households experiencing food insecurity

OBJECTIVE

Food insecurity is a potent determinant of health and indicator of material deprivation in many affluent countries. Food insecurity is associated with compromises in food and housing expenditures, but how it relates to other expenditures is unknown. The present study described households' resource allocation over a 12-month period by food insecurity status.

DESIGN

Expenditure data from the 2010 Survey of Household Spending were aggregated into four categories (basic needs, other necessities, discretionary, investments/assets) and ten sub-categories (food, clothing, housing, transportation, household/personal care, health/education, leisure, miscellaneous, personal insurance/pension, durables/assets). A four-level food insecurity status was created using the adult-specific items of the Household Food Security Survey Module. Mean dollars spent and budget share by food insecurity status were estimated with generalized linear models adjusted first for household size and composition, and subsequently for after-tax income quartiles.

SETTING

Canada.

SUBJECTS

Population-based sample of households from the ten provinces (n 9050).

RESULTS

Food-secure households had higher mean total expenditures than marginally, moderately and severely food-insecure households (P-trend <0·0001). As severity of food insecurity increased, households spent less on all categories and sub-categories, except transportation, but they allocated a larger budget share to basic needs and smaller shares to discretionary spending and investments/assets. The downward trends for dollars spent on basic needs and other necessities became non-significant after accounting for income, but the upward trend in the budget shares for basic needs persisted.

CONCLUSIONS

The spending patterns of food-insecure households suggest that they prioritized essential needs above all else.

Prevalence and Correlates of Food Insecurity among Students Attending a Small, Rural Canadian University

PURPOSE

University students may be at risk for food insecurity (FI) due to low income coupled with rising tuition, housing, and food costs. This study aimed to determine the prevalence of FI and potential correlates among students at a small, rural Canadian university.

METHODS

Health Canada's 10-item household food security survey module (HFSSM) was adapted to assess food security status within the postsecondary student population. An additional 11 items measured food access and demographics. The validated, web-based survey was distributed by email and completed by 218 students (15.6% response rate). Participants were classified as food secure, moderately food insecure, or severely food insecure using the HFSSM Adult scale.

RESULTS

An overall FI rate of 37.2% was observed. This included 25.7% moderately food insecure and 11.5% severely food insecure. Students in higher years of study and who lived off campus had higher rates of FI.

CONCLUSIONS

FI appears to be a significant concern for university students and has potential health and academic implications. Further research is needed to clarify the determinants and extent of FI for postsecondary students and to develop strategies to mitigate the prevalence and effects of food insecurity in these young adults.

Food Insecurity in Older Adults in an Integrated Health Care System

OBJECTIVES

To estimate food insecurity prevalence and develop a statistical prediction model for food insecurity.

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Colorado.

PARTICIPANTS

Adult members who completed a pre-Medicare Annual Wellness Visit survey.

MEASUREMENTS

Food insecurity was assessed using a single screening question. Sociodemographic and clinical characteristics from electronic health records and self-reported characteristics from the survey were used to develop the prediction model.

RESULTS

Of 130,208 older adult members between January 2012 and December 2015, 50,097 (38.5%) completed food insecurity screening, 2,859 of whom (5.7% of respondents) reported food insecurity. The prevalence of food insecurity was 10.0% or greater among individuals who were black or Hispanic, had less than high school education, had Medicaid insurance, were extremely obese, had poor health status or quality of life, had depression or anxiety, had impairments in specific activities of daily living, had other nutritional risk factors, or were socially isolated (all p<.001). A multivariable model based on these and other characteristics showed moderate discrimination (c-statistic = 0.74) between individuals with food insecurity and those without and 14.3% of individuals in the highest quintile of risk reported food insecurity.

CONCLUSION

Food insecurity is prevalent even in older adults with private-sector healthcare coverage. Specific individual characteristics, and a model based on those characteristics, can identify older adults at higher risk of food insecurity. System-level interventions will be necessary to connect older adults with community-based food resources.

Food Insecurity Is Associated with Low Adherence to the Mediterranean Diet and Adverse Health Conditions in Portuguese Adults

Background

Food insecurity is a limited or uncertain access to the adequate food and is a significant public health problem. We aimed to assess determinants of food insecurity and the corresponding health impact in Portugal, a southern European country that faced a severe economic crisis.

Methods

Data were derived from the Epidemiology of Chronic Diseases Cohort Study (EpiDoC), a population-based cohort of 10,661 individuals that were representative of the Portuguese adult population and followed since 2011. A cross-sectional analysis of the third wave of evaluation (EpiDoC 3) was performed between 2015 and 2016. Food insecurity was assessed with the household food insecurity psychometric scale. Socioeconomic, demographic, lifestyle, adherence to Mediterranean diet (MD), self-reported non-communicable disease, health-related quality of life (HRQoL) (EQ-5D-3L), physical function (HAQ score), and health resource consumption information was also collected.

Results

The estimated proportion of food insecurity was 19.3% among a total of 5,653 participants. Food insecure households had low adherence to the MD (OR = 0.44; 95% IC 0.31–0.62). In addition, diabetes (OR = 1.69; 95% IC 1.20–2.40), rheumatic disease (OR = 1.67; 95% IC 1.07–2.60), and depression symptoms (OR = 1.50; 95% IC 1.09–2.06) were independently associated with food insecurity. On average, food insecure households had a lower HRQoL (OR = 0.18; 95% IC 0.11–0.31) and a higher disability (OR = 2.59; 95% IC 2.04–3.29). A significantly higher proportion of food insecure households reported being hospitalized (OR = 1.57; 95% IC 1.18–2.07) and had more public hospital medical appointments (OR = 1.48; 95% IC 1.12–1.94) in the previous 12 months.

Conclusion

We found that food insecurity is highly prevalent in Portugal. Food insecurity was associated with low adherence to the MD, non-communicable chronic diseases, lower quality of life, and higher health resource consumption. Therefore, this study provides valuable insight into the relationship between food security and the diet and health of the population during an economic crisis.

"Nothing is going to change three months from now": A mixed methods characterization of food bank use in Greater Vancouver

North American food bank use has risen dramatically since the 1980s, and over 850,000 Canadians were estimated to have visited a food bank monthly in 2015. Food banks serve multiple roles in communities, ranging from 'emergency responses' to individualized and short-term experiences of hunger, to 'chronic' supports as part of long-term subsistence strategies. This study used a mixed-methods design to examine the spectrum of food bank user experiences in a large urban context, as part of a community-based project aiming to envision a redesign of the food bank to contribute to broader community food security outcomes. Survey (n = 77) and focus group (n = 27) results suggested that participants widely viewed food banks as a long-term food-access strategy. Inadequate financial resources, steep increases in housing and food costs, and long-term health challenges emerged as the most prominent factors influencing food bank use. Participants commonly reported unmet food needs despite food bank use, limited agency over factors influencing access to sufficient food, and anticipated requiring food bank services in future. These findings contest global constructions of food banks as "emergency" food providers and support growing evidence that food banks are an insufficient response to chronic poverty, lack of affordable housing and insufficient social assistance rates underlying experiences of food insecurity. Participants envisioned changes to the food bank system to increase community food security including improved food quality and quantity (short-term), changes to service delivery and increased connections with health services (capacity building), and a greater role in poverty reduction advocacy (system redesign).

Lessons Learned from Implementation of the Food Insecurity Screening and Referral Program at Kaiser Permanente Colorado

Traditionally, health care systems have addressed gaps in patients' diet quality with programs that provide dietary counseling and education, without addressing food security. However, health care systems increasingly recognize the need to address food security to effectively support population health and the prevention and management of diet-sensitive chronic illnesses. Numerous health care systems have implemented screening programs to identify food insecurity in their patients and to refer them to community food resources to support food security. This article describes barriers encountered and lessons learned from implementation and expansion of the Kaiser Permanente Colorado's clinical food insecurity screening and referral program, which operates in collaboration with a statewide organization (Hunger Free Colorado) to manage clinic-to-community referrals. The immediate goals of clinical screening interventions described in this article are to identify households experiencing food insecurity, to connect them to sustainable (federal) and emergency (community-based) food resources, to alleviate food insecurity, and to improve dietary quality. Additional goals are to improve health outcomes, to decrease health care utilization, to improve patient satisfaction, and to better engage patients in their care.

Status report - FoodReach Toronto: lowering food costs for social agencies and community groups

Toronto has the largest absolute number of food insecure households for any metropolitan census area in Canada: of its 2.1 million households, roughly 252 000 households (or 12%) experience some level of food insecurity. Community organizations (including social agencies, school programs, and child care centres) serve millions of meals per year to the city's most vulnerable citizens, but often face challenges accessing fresh produce at affordable prices. Therefore in 2015, Toronto Public Health, in collaboration with public- and private-sector partners, launched the FoodReach program to improve the efficiency of food procurement among community organizations by consolidating their purchasing power. Since being launched, FoodReach has been used by more than 50 community organizations to provide many of Toronto's most marginalised groups with regular access to healthy produce.

Position of the Academy of Nutrition and Dietetics: Food Insecurity in the United States

It is the position of the Academy of Nutrition and Dietetics that systematic and sustained action is needed to achieve food and nutrition security in the United States. To achieve food security, effective interventions are needed, along with adequate funding for, and increased utilization of, food and nutrition assistance programs; inclusion of nutrition education in such programs; strategies to support individual and household economic stability; and research to measure impact on food insecurity- and health-related outcomes. Millions of individuals living in the United States experience food insecurity. Negative nutritional and non-nutritional outcomes are associated with food insecurity across the lifespan, including substandard academic achievement, inadequate intake of key nutrients, increased risk for chronic disease, and poor psychological and cognitive functioning. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, play key roles in addressing food insecurity and are uniquely positioned to make valuable contributions through competent and collaborative practice, provision of comprehensive food and nutrition education and training, innovative research related to all aspects of food insecurity, and advocacy efforts at the local, state, regional, and national levels.

The household food insecurity gradient and potential reductions in adverse population mental health outcomes in Canadian adults

PURPOSE

Household food insecurity is related to poor mental health. This study examines whether the level of household food insecurity is associated with a gradient in the risk of reporting six adverse mental health outcomes. This study further quantifies the mental health impact if severe food insecurity, the extreme of the risk continuum, were eliminated in Canada.

METHODS

Using a pooled sample of the Canadian Community Health Survey (N = 302,683), we examined the relationship between level of food insecurity, in adults 18-64 years, and reporting six adverse mental health outcomes. We conducted a probit analysis adjusted for multi-variable models, to calculate the reduction in the odds of reporting mental health outcomes that might accrue from the elimination of severe food insecurity.

RESULTS

Controlling for various demographic and socioeconomic covariates, a food insecurity gradient was found in six mental health outcomes. We calculated that a decrease between 8.1% and 16.0% in the reporting of these mental health outcomes would accrue if those who are currently severely food insecure became food secure, after controlling for covariates.

CONCLUSION

Household food insecurity has a pervasive graded negative effect on a variety of mental health outcomes, in which significantly higher levels of food insecurity are associated with a higher risk of adverse mental health outcomes. Reduction of food insecurity, particularly at the severe level, is a public health concern and a modifiable structural determinant of health worthy of macro-level policy intervention.

Please sir, I want some more: an exploration of repeat foodbank use

Background

The sharp rise in foodbank use in Britain over the past five years suggests a proliferation of food insecurity that could herald a public health crisis. However, trends in foodbank use rely on imperfect figures that do not distinguish between single and repeat visits. Consequently, the true prevalence of foodbank use in Britain is unknown. By identifying repeat visits, this study provides the first estimate of the proportion of people using foodbanks.

Methods

Using data on referrals to West Cheshire Foodbank in the UK, this study offers a case study of 7769 referrals to one foodbank between 2013 and 2015. Foodbank use was explored in descriptive statistics, then negative binomial regression models were used to identify the household characteristics associated with the number of foodbank visits.

Results

Between 0.9 and 1.3% of people in West Cheshire sought assistance from West Cheshire Foodbank between 2013 and 2015. If scaled up nationally, this would equate to an estimated 850,000 people across Britain. The number of total recipients increased by 29% between 2013 and 2015, while the number of unique recipients rose by 14%. Multivariate analysis revealed that a larger number of visits were recorded in 2015 and among working-age and one-person households, while households referred due to domestic abuse and unemployment made fewer visits.

Conclusion

Food insecurity has emerged as a crucial challenge facing UK health professionals and policymakers. This study provides the first estimate of the proportion of individuals receiving emergency food in a single case study location, and demonstrates that foodbank use is becoming more prevalent, although headline figures overstate the scale of this growth. The potential nutrition and wider health consequences of reliance on emergency food – especially among those using foodbanks on multiple occasions – warns of an unfolding public health crisis.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4847-x) contains supplementary material, which is available to authorized users.

Supplemental Nutrition Assistance Program (SNAP) Participation and Health Care Expenditures Among Low-Income Adults

IMPORTANCE

Food insecurity is associated with high health care expenditures, but the effectiveness of food insecurity interventions on health care costs is unknown.

OBJECTIVE

To determine whether the Supplemental Nutrition Assistance Program (SNAP), which addresses food insecurity, can reduce health care expenditures.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort study of 4447 noninstitutionalized adults with income below 200% of the federal poverty threshold who participated in the 2011 National Health Interview Survey (NHIS) and the 2012-2013 Medical Expenditure Panel Survey (MEPS).

EXPOSURES

Self-reported SNAP participation in 2011.

MAIN OUTCOMES AND MEASURES

Total health care expenditures (all paid claims and out-of-pocket costs) in the 2012-2013 period. To test whether SNAP participation was associated with lower subsequent health care expenditures, we used generalized linear modeling (gamma distribution, log link, with survey design information), adjusting for demographics (age, gender, race/ethnicity), socioeconomic factors (income, education, Social Security Disability Insurance disability, urban/rural), census region, health insurance, and self-reported medical conditions. We also conducted sensitivity analyses as a robustness check for these modeling assumptions.

RESULTS

A total of 4447 participants (2567 women and 1880 men) were enrolled in the study, mean (SE) age, 42.7 (0.5) years; 1889 were SNAP participants, and 2558 were not. Compared with other low-income adults, SNAP participants were younger (mean [SE] age, 40.3 [0.6] vs 44.1 [0.7] years), more likely to have public insurance or be uninsured (84.9% vs 67.7%), and more likely to be disabled (24.2% vs 10.6%) (P < .001 for all). In age- and gender-adjusted models, health care expenditures between those who did and did not participate in SNAP were similar (difference, $34; 95% CI, -$1097 to $1165). In fully adjusted models, SNAP was associated with lower estimated annual health care expenditures (-$1409; 95% CI, -$2694 to -$125). Sensitivity analyses were consistent with these results, also indicating that SNAP participation was associated with significantly lower estimated expenditures.

CONCLUSIONS AND RELEVANCE

SNAP enrollment is associated with reduced health care spending among low-income American adults, a finding consistent across several analytic approaches. Encouraging SNAP enrollment among eligible adults may help reduce health care costs in the United States.

Prevalence and predictors of food insecurity among people living with HIV affiliated with AIDS service organizations in Ontario, Canada

Up to half of people living with HIV in resource-rich settings experience moderate to severe food insecurity. Food insecurity, in turn, has been linked to adverse health outcomes including poor antiretroviral adherence, poor HIV viral suppression, frailty, and mortality. We estimated the prevalence of food insecurity among 649 adults living with HIV and recruited from community-based AIDS service organizations in Ontario, Canada. Food security was assessed using the Canadian Household Food Security module. We used logistic regression modeling to identify demographic, socioeconomic, and psychosocial factors independently associated with food insecurity. Almost three-fourths of participants (70.3%) were food insecure and a third (31%) reported experiencing hunger. The prevalence of food insecurity in this sample is approximately six times higher than that of the general population. Factors independently associated with food insecurity were: having dependent children at home, residing in large urban areas, low annual household income (<$40,000), difficulty meeting housing-related expenses, cigarette smoking, harmful drug use, and depression. Broad, multisector interventions that address income, housing affordability, substance use and mental health issues are needed and could offset future public health expenditures.

Implementation and impact of an online tool used in primary care to improve access to financial benefits for patients: a study protocol

OBJECTIVES

Addressing the social determinants of health has been identified as crucial to reducing health inequities. However, few evidence-based interventions exist. This study emerges from an ongoing collaboration between physicians, researchers and a financial literacy organisation. Our study will answer the following: Is an online tool that improves access to financial benefits feasible and acceptable? Can such a tool be integrated into clinical workflow? What are patient perspectives on the tool and what is the short-term impact on access to benefits?

METHODS

An advisory group made up of patients living on low incomes and representatives from community agencies supports this study. We will recruit three primary care sites in Toronto, Ontario and three in Winnipeg, Manitoba that serve low-income communities. We will introduce clinicians to screening for poverty and how benefits can increase income. Health providers will be encouraged to use the tool with any patient seen. The health provider and patient will complete the online tool together, generating a tailored list of benefits and resources to assist with obtaining these benefits. A brief survey on this experience will be administered to patients after they complete the tool, as well as a request to contact them in 1 month. Those who agree to be contacted will be interviewed on whether the intervention improved access to financial benefits. We will also administer an online survey to providers and conduct focus groups at each site.

ETHICS AND DISSEMINATION

Key ethical concerns include that patients may feel discomfort when being asked about their financial situation, may feel obliged to complete the tool and may have their expectations falsely raised about receiving benefits. Providers will be trained to address each of these concerns. We will share our findings with providers and policy-makers interested in addressing the social determinants of health within healthcare settings.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov: NCT02959866. Registered 7 November 2016. Retrospectively registered. Pre-results.

Outcomes of disease prevention and management interventions in food pantries and food banks: protocol for a scoping review

INTRODUCTION

Food insecurity is a difficulty faced in many households. During periods of food insecurity, households often seek food supplied by food pantries and food banks. Food insecurity has been associated with increased risk for several health conditions. For this reason, food pantries and food banks may have great promise as intervention sites, and health researchers have begun targeting food pantries and food banks as sites for disease prevention or management interventions. The aim of the scoping review is to examine disease prevention or management interventions implemented in food pantries and food banks.

METHODS AND ANALYSIS

Relevant electronic databases (eg, MEDLINE, Cumulative Index to Nursing and Allied Health Literature-CINAHL Complete, Science Citation Index, Cochrane Database of Systematic Reviews) will be searched for articles with a publication date of 1997 or later using Medical Subject Headings and key terms, including food aid, food banks, food pantries, food shelves, hunger, food insecurity and related concepts. For each de-duplicated study record identified by the search strategy, two reviewers will independently assess whether the study meets eligibility criteria (eg, related to intervention type, context). The reviewers will examine studies' titles, abstracts and full text, comparing eligibility decisions to address any discrepancies. For each eligible study, data extraction will be executed by two reviewers independently, comparing extracted data to address any discrepancies. Extracted data will be synthesised and reported in a narrative review assessing the coverage and gaps in existing literature related to disease prevention and management interventions implemented in food pantries.

ETHICS AND DISSEMINATION

The review's results will be useful to healthcare practitioners who work with food-insecure populations, healthcare researchers and food pantry or food bank personnel. The results of this scoping review will be submitted for publication to a peer-reviewed journal, and the authors will share the findings with food pantry and food bank stakeholder groups with whom they work.

Food assistance is associated with decreased nursing home admissions for Maryland's dually eligible older adults

BACKGROUND

Although it has long been known that a broad range of factors beyond medical diagnoses affect health and health services use, it has been unclear whether additional income can decrease health service use. We examined whether Supplemental Nutrition Assistance Program (SNAP) receipt is associated with subsequent nursing home entry among low income older adults.

METHODS

We examined the 77,678 older adults dually eligible for Medicaid and Medicare in Maryland, 2010-2012. Zero inflated negative binomial regression, adjusting for demographic and health factors, tested the association of either lagged SNAP enrollment or lagged benefit amount with nursing home admission. We used Heckman two-step model results to calculate potential savings of SNAP enrollment through reduced nursing home admissions and reduced duration.

RESULTS

Only 53.4% received SNAP in 2012, despite being income-eligible. SNAP participants had a 23% reduced odds of nursing home admission than nonparticipants (95% CI: 0.75-0.78). For SNAP participants, an additional $10 of monthly SNAP assistance was associated with lower odds of admission (OR = 0.93, 95% CI: 0.93-0.93), and fewer days stay among those admitted (IRR = 0.99, 95% CI: 0.98-0.99). Providing SNAP to all 2012 sample nonparticipants could be associated with $34 million in cost savings in Maryland.

CONCLUSIONS

SNAP is underutilized and may reduce costly nursing home use among high-risk older adults. This study has policy implications at the State and Federal levels which include expanding access to SNAP and enhancing SNAP amounts.

The association between food insecurity and academic achievement in Canadian school-aged children

OBJECTIVE

Education is a crucial social determinant of health. Food insecurity can be detrimental to children's academic achievement, potentially perpetuating a cycle of poverty and food insecurity. We aimed to assess the relationship between food insecurity and academic achievement in Canadian school-aged children.

DESIGN

Cross-sectional study of children and parents. Parents completed the short-form Household Food Security Survey Module and questions about income and education level (socio-economic status). Children completed FFQ. Data were prospectively linked to children's performance on standardized exams written one year later. Mixed-effect logistic regression was employed to assess the relationship between food insecurity and likelihood of meeting academic expectations adjusting for socio-economic status, diet quality and potential confounders.

SETTING

Nova Scotia, Canada in 2011-2012.

SUBJECTS

Students (n 4105) in grade 5 (10-11 years; 2167 girls) and their parents.

RESULTS

Low food security was reported by 9·8 % of households; very low food security by 7·1 % of households. Students from low-income households and reporting poor diet quality were less likely to do well in school. Children who lived in households reporting very low food security had 0·65 times the odds (OR=0·65; 95 % CI 0·44, 0·96) of meeting expectations for reading and 0·62 times the odds (OR=0·62; 95 % CI 0·45, 0·86) of meeting expectations for mathematics.

CONCLUSIONS

Very low household insecurity is associated with poor academic achievement among children in Nova Scotia.

Adults' food skills and use of gardens are not associated with household food insecurity in Canada

OBJECTIVES

To determine the extent to which Canadian adults' food preparation and cooking skills and use of home or community gardens relate to their household food insecurity status; and to compare the food shopping and cooking behaviours of adults in food-secure and food-insecure households.

METHODS

Data were drawn from two Rapid Response Modules appended to the Canadian Community Health Survey in 2012 and 2013. The analytic sample comprised 16,496 respondents 18 years and older. Multivariable logistic regression analyses were conducted to determine the association between food insecurity and adults' self-rated cooking abilities, food preparation skills score, use of gardens, food shopping behaviours, and cooking behaviours, while adjusting for socio-demographic characteristics.

RESULTS

Adults in food-insecure households did not differ significantly from others with respect to their food preparation skills or cooking ability, and neither variable predicted the odds of household food insecurity when socio-demographic characteristics were taken into account. Adults in food-insecure households were less likely to use a garden for food, but gardening was unrelated to the odds of food insecurity. Shopping with a budget was more common among adults in food-insecure households, but no other differences in food shopping behaviours were observed after adjustment for socio-demographic characteristics. Adults in food-insecure households were as likely as others to adjust recipes to make them healthier, but they had higher odds of adjusting recipes to reduce their fat content.

CONCLUSION

Our findings suggest that household food insecurity in Canada is not a problem of insufficient food skills.

High vulnerability to household food insecurity in a sample of Canadian renter households in government-subsidized housing

OBJECTIVES

To determine the prevalence and severity of household food insecurity and examine household material circumstances related to food insecurity in a sample of renter households in government-subsidized housing.

METHODS

Cross-sectional data from the 2010 Survey of Household Spending were used to determine the food insecurity status of 455 renter households living in the 10 provinces and receiving a government housing subsidy. Multivariable logistic regressions were conducted to examine the relationship between household characteristics describing material circumstances and food insecurity.

RESULTS

One in two households was food insecure. Marginal, moderate and severe food insecurity affected 9.0%, 23.3% and 18.5% of households respectively. Household economic resources, as captured with after-tax income, after-rent income, or total expenditure, had an independent, inverse relationship with food insecurity. Among the other characteristics examined, more adults or children in the household, presence of a member with disability, and receipt of social assistance increased the odds of food insecurity, but receipt of social assistance lost statistical significance when controlling for total expenditure. Presence of a senior in the household was independently associated with lower odds of food insecurity.

CONCLUSION

Our findings suggest that more effective income-based interventions are needed to address food insecurity among low-income households receiving government housing subsidies. A better integration of housing and income-based policies is necessary to support household food security among government-subsidized renter households.

Brief assessment of food insecurity accurately identifies high-risk US adults

OBJECTIVE

To facilitate the introduction of food insecurity screening into clinical settings, we examined the test performance of two-item screening questions for food insecurity against the US Department of Agriculture's Core Food Security Module.

DESIGN

We examined sensitivity, specificity and accuracy of various two-item combinations of questions assessing food insecurity in the general population and high-risk population subgroups.

SETTING

2013 Current Population Survey December Supplement, a population-based US survey.

SUBJECTS

All survey participants from the general population and high-risk subgroups.

RESULTS

The test characteristics of multiple two-item combinations of questions assessing food insecurity had adequate sensitivity (>97 %) and specificity (>70 %) for widespread adoption as clinical screening measures.

CONCLUSIONS

We recommend two specific items for clinical screening programmes based on their widespread current use and high sensitivity for detecting food insecurity. These items query how often the household 'worried whether food would run out before we got money to buy more' and how often 'the food that we bought just didn't last and we didn't have money to get more'. The recommended items have sensitivity across high-risk population subgroups of ≥97 % and a specificity of ≥74 % for food insecurity.

The impact of changes in social policies on household food insecurity in British Columbia, 2005-2012

As concerns about food insecurity in high income countries grow, there is a need to better understand the impact of social policy decisions on this problem. In Canada, provincial government actions are particularly important because food insecurity places substantial burden on provincial health care budgets. This study was undertaken to describe the socio-demographic and temporal patterning of food insecurity in British Columbia (BC) from 2005 to 2012 and determine the impact of BC's one-time increase in social assistance and introduction of the Rental Assistance Program (RAP) on food insecurity rates among target groups. Using data from the Canadian Community Health Surveys, logistic regression analyses were conducted to identify trends and assess changes in food insecurity among subgroups differentiated by main source of income and housing tenure. Models were run against overall food insecurity, moderate and severe food insecurity, and severe food insecurity to explore whether the impact of policy changes differed by severity of food insecurity. Overall food insecurity rose significantly among households in BC between 2005 and 2012. Following the increase in social assistance benefits, overall food insecurity and moderate and severe food insecurity declined among households on social assistance, but severe food insecurity remained unchanged. We could discern no effect of the RAP on any measure of food insecurity among renter households. Our findings indicate the sensitivity of food insecurity among social assistance recipients to improvements in income and highlight the importance of examining severity of food insecurity when assessing the effects of policy interventions.

Immigrant Health in Toronto, Canada: Addressing Food Insecurity as a Social Determinant of Tuberculosis

In Canada, tuberculosis is 20 times more likely to be experienced by new immigrants than by Canadian citizens. Food insecurity, which has implications for developing tuberculosis, is linked to poverty and immigration status and has costly implications for individuals and public health. This article explores the history of the Ontario government's failure to adequately address poverty and food insecurity and the role of social work in addressing these issues. Recommendations for addressing food insecurity at a policy level include increasing the rate and goals of the Ontario Works program. Implications for new immigrants, tuberculosis and public health are explored.

Impact of a guaranteed annual income program on Canadian seniors' physical, mental and functional health

OBJECTIVE

Although there is widespread recognition that poverty is a key determinant of health, there has been less research on the impact of poverty reduction on health. Recent calls for a guaranteed annual income (GAI), defined as regular income provided to citizens by the state regardless of work status, raise questions about the impact, relative to the costs, of such a population health intervention. The objective of this study was to determine the impact of Canadian seniors' benefits (Old Age Security/Guaranteed Income Supplement, analogous to a GAI program) on the self-reported health, self-reported mental health and functional health of age-eligible, low-income seniors.

METHODS

We used the 2009-2010 Canadian Community Health Survey to examine unattached adult respondents with an annual income of $20,000 or less, stratified by seniors' benefits/GAI eligibility (55-64 years: ineligible; 65-74 years: eligible). Using regression, we assessed self-reported health, selfreported mental health and functional health as measured by the Health Utilities Index, as outcomes for seniors' benefits/GAI-eligible and -ineligible groups.

RESULTS

We found that individuals age-eligible for seniors' benefits/GAI had better health outcomes than recipients of conditional income assistance programs. Eligibility for seniors' benefits/GAI after age 64 was associated with better self-reported health, functional health and self-reported mental health outcomes, and these effects were observed until age 74.

CONCLUSION

Using seniors' benefits as an example, a GAI leads to significantly better mental health and improved health overall. These improvements are likely to yield reduced health care costs, which may offset the costs associated with program expansion.

Exploring experiences of the food environment among immigrants living in the Region of Waterloo, Ontario

OBJECTIVES

This exploratory study aimed to shed light on the role of the food environment in shaping food access among immigrants living in the Region of Waterloo, Ontario.

METHODS

In this qualitative case study, in-depth interviews aided by photovoice were conducted with nine immigrants, and key informant (KI) interviews were conducted with nine community stakeholders (e.g., settlement workers, planners) who held expert knowledge of the local context with respect to both the food system and experiences of immigrants in interacting with this system. In this paper, we focus specifically on insights related to the food environment, applying the Analysis Grid for Environments Linked to Obesity Framework to assess economic, physical, socio-cultural and political aspects.

RESULTS

Economic features of the food environment, including food prices and differential costs of different types of food, emerged as factors related to food access. However, interactions with the food environment were shaped by broader economic factors, such as limited employment opportunities and low income. Most immigrants felt that they had good geographic access to food, though KIs expressed concerns about the types of outlet and food that were most accessible. Immigrants discussed social networks and cultural food practices, whereas KIs discussed political issues related to supporting food security in the Region.

CONCLUSION

This exploratory case study is consistent with prior research in highlighting the economic constraints within which food access exists but suggests that there may be a need to further dissect food environments.

A Public Policy Advocacy Project to Promote Food Security: Exploring Stakeholders' Experiences

To achieve food security in Canada, comprehensive approaches are required, which involve action at the public policy level. This qualitative study explored the experiences of 14 stakeholders engaging in a 9-month participatory public policy advocacy project to promote community food security in the province of Alberta through the initiation of a campaign to develop a Universal School Food Strategy. Through this exploration, four main themes were identified; a positive and open space to contribute ideas, diversity and common ground, confidence and capacity, and uncertainty. Findings from this study suggest that the participatory advocacy project provided a positive and open space for stakeholders to contribute ideas, through which the group was able to narrow its focus and establish a goal for advocacy. The project also seems to have contributed to the group's confidence and capacity to engage in advocacy by creating a space for learning and knowledge sharing, though stakeholders expressed uncertainty regarding some aspects of the project. Findings from this study support the use of participatory approaches as a strategy for facilitating engagement in public policy advocacy and provide insight into one group's advocacy experience, which may help to inform community-based researchers and advocates in the development of advocacy initiatives to promote community food security elsewhere.

Food Insecurity and Health Care Utilization Among Older Adults

This study examined the relationship between food insecurity and health care utilization (physician, inpatient, emergency room, and home health visits) among older adults. Survey data collected from Georgia Advanced Performance Outcomes Measures Project 6 linked to the Centers for Medicare and Medicaid Services (GA Advanced POMP6-CMS) data 2008 ( N = 957) were analyzed. Nearly one half of the sample (48.3%) was food insecure. Food insecure individuals were significantly less likely than food secure individuals to have any physician (69.7% vs. 80.2%) and home health visits (24.9% vs. 32.3%) during 2008. However, there were no significant differences in levels of health care utilization by food secure and food insecure older adults. Food secure and food insecure older adults utilized comparable levels of health care services. Public assistance programs such as Medicare and meal services targeted toward older adults may enable economically constrained, food insecure older adults to access needed health care services.