Developing and Piloting a Tool to Identify Food Insecurity in Older Adults

Development of an older adult Nutrition Equity Index (NEI) and association with the Healthy Eating Index (HEI) in older Black and White U.S. adults

OBJECTIVES

We developed a novel measure for older U.S. adults called the Nutrition Equity Index (NEI), which includes functional ability. We compared both the NEI and food insufficiency with Healthy Eating Index (HEI) scores.

DESIGN

The Health, Aging, and Body Composition Study is a prospective, longitudinal cohort of Medicare-eligible, community-dwelling Black and White men and women.

SETTING

Pittsburgh, PA and Memphis, TN.

PARTICIPANTS

Participants (N = 2468, aged 74.7 ± 2.9 years) had baseline (1997-98) and 1-year follow-up NEI data; and 1 year follow-up for food insufficiency, key covariates, and the HEI (diet quality measure) from a 108-item interviewer-administered food frequency questionnaire.

MEASUREMENTS

Food insufficiency was defined from a modified validated question on ample food amount/variety from the U.S. Department of Agriculture. NEI was constructed from 8 questions in three subdomains: food insecurity (food insufficiency, hunger, anxiety about limited food, limited money for food), food access (groceries), and food acquisition (difficulty shopping, preparing meals, carrying groceries). Final NEI categories were low nutrition equity (0), moderate nutrition equity (1), and high nutrition equity (2). Multivariable linear regression compared both NEI and food insufficiency with HEI, adjusted for sociodemographic, lifestyle and comorbidity factors.

RESULTS

Of participants, 13.5% had food insufficiency, 12.1% had low NEI, and 32.5% had moderate NEI. Participants with food insufficiency (vs. food sufficiency) or low NEI (vs. high NEI) were more likely to be Black and have < high school education (both p < 0.0001). In minimally adjusted models, food insufficiency was associated with 2.2 point lower HEI score (p = 0.001), low NEI with 2.6 point lower HEI score (p = 0.001), and moderate NEI with 1.0 point lower HEI score (p < 0.05). Adjusting for race attenuated NEI associations with HEI to non-significance. After multivariable adjustment, food insufficiency was associated with 1.5 point lower HEI score (p = 0.03).

CONCLUSION

Food insufficiency was associated with lower dietary quality in this sample of older Black and White U.S. adults. NEI performed similarly to food insufficiency for HEI associations prior to multivariable adjustment and identified more older adults with nutrition inequity, who may be at risk for poor health outcomes.

Implementing a Process for Screening Hospitalized Adults for Food Insecurity at a Tertiary Care Center

ABSTRACT

Food insecurity has been linked to numerous chronic conditions and higher healthcare costs; however, screening for food insecurity lags behind screening for other social determinants of health, particularly in the hospital setting. Although our hospital serves a population with a high prevalence of food insecurity, no process previously existed to universally screen patients. Our multidisciplinary team developed and implemented a process to screen hospitalized adults for food insecurity and connect them with food resources, which we piloted on a 26-bed hospital medicine unit. We integrated a validated 2-item screen into the electronic health record (EHR) nursing admission workflow, and provided 2 weeks of nursing education before process implementation. Adherence to screening was monitored weekly and adjustments were made using plan-do-study-act cycles. After 28 weeks, 361/587 (61.5%; weekly average 61.1%) encounters were screened (compared with a baseline of 2.2%), with 21/361 (5.8%) identified as food insecure. The implementation of an EHR-based food insecurity screening process in the hospital setting increased screening and identification of food insecure patients. Through improved integration of screening questions into the existing nursing workflow and continued education, success was sustained despite challenges with nursing staff turnover and staff shortages during the COVID-19 pandemic.