Addressing Food Insecurity in Pharmacist Practice

Food insecurity is defined as a lack of available resources for a sufficient quantity of affordable and nutritious food at the household level. According to the Feeding America organization, 42 million people (1 in 8), including 13 million children (1 in 6), in the United States had disruption of food intake or eating patterns because of lack of money and other resources in 2021.¹

This is slight improvement over what occurred in 2020, when the COVID-19 pandemic escalated the problem and 45 million people, including 13 million children, suffered because of food insecurity.¹ As such, much work is needed to improve this situation in 2022.

Every health care professional should be concerned about food insecurity and must help to overcome the stigma and identify vulnerable populations. Pharmacists can help to reduce the prevalence of food insecurity and its negative health care outcomes by tailoring clinical care to each individual patient’s needs. As a profession, we are responsible for preventing negative pharmaceutical and health care outcomes driven by poor access to healthy foods, as well as to educate patients regarding where they may receive support.

However, food insecurity may affect everyone and it is not only related to access to food. Many individuals experiencing this problem have no access to fresh and high-quality nutritious meals. Everyone may experience food insecurity because of unemployment, change in family situation, change in health, disability of individual or family member, homelessness, and a lack of transportation, among other reasons. Food insecurity can affect individuals across demographics and regions.

Families affected by food insecurity and a lack of opportunities to meet their basic needs often are forced into inadvisable or even unavoidable choices, such as replacing products of a good quality with nutrient-poor products, not sending children to school, or simply restricting food intake. The effects of such choices are destructive to their health. The increase in food prices following the COVID-19 pandemic made healthy options less accessible, especially for the families of the lowest income.

Food insecurity is a complex problem and a key social determinant of health because it affects outcomes. People with a limited ability to have a balanced diet have a higher risk of developing chronic diseases.

Food-insecure senior patients are 50% more likely to develop diabetes as well as obesity and diet-related health conditions.² They are 60% more likely to have congestive heart disease or experience a heart attack and 14% more likely to have hypertension.²

Food insecure patients also have a higher risk of other cardiovascular diseases, including coronary heart disease and stroke. In addition, they are twice as likely to have asthma and chronic obstructive pulmonary disease.² It also increases negative outcomes for pregnant patients.

Hepatitis, cancer, arthritis, and anemia are very common in this population. Food insecurity also affects psychological health and may lead to anxiety and depression.

In children, it may lead to deficits in socio-emotional, cognitive, and motor functioning. Older patients have a diminished capacity to maintain independence while aging if they were food insecure in the past.

According to the study Hunger in America, 66% of households had to choose between food and medical care in 2014.³ This can lead to medications non-adherence, poor disease self-management, mask underlying health conditions, cause misdiagnosis, and subsequently lead to more and longer hospitalizations with increased health costs.

For pharmacists and technicians screening for food insecure individuals, it is important to talk openly and tactfully while eliminating unconscious bias. Patients are asked to answer to the following statements with the answers “often true, sometimes true, or never true.”

• “Within the past 12 months, we worried whether our food would run out before we had money to buy more.”
• “Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.”

If the response to either statement is often true or “sometimes true, the individuals are identified as food insecure.⁴ Patients should be consulted how food insecurity may lead to undesirable health outcomes and how to prevent medications adverse reactions.

If patients have diabetes and are using insulins, taking sulfonylurea or meglitinides, they should be informed about the risks, signs, and symptoms of hypoglycemia, as well as how to act in case of emergency. If using insulin, patients must know how to adjust doses.

If patients are taking meglitinides, it is recommended to skip the dose when they skip a meal. Metformin should be taken with meals because it may reduce gastrointestinal adverse effects (AEs), especially when starting therapy. Because of its unique mechanism of action, acarbose should be taken with food or swallowed whole with a little liquid immediately before food.

Some medications, including allopurinol and bromocriptine, must be taken after meals to reduce AEs such as nausea and vomiting. Aspirin, non-steroidal anti-inflammatory drugs, and steroids should be taken with meals to reduce the risk of stomach irritation or ulcer formation.

Food is needed to ensure the medicine is absorbed into the bloodstream in the case of taking ritonavir, griseofulvin, and itraconazole (capsules only).

Carvedilol should be taken with food to slow its rate of absorption and to reduce the risk of orthostatic hypotension.

These are just a few examples. There are more medications that should be taken before or with a meal because of their pharmacokinetics, absorption requirements, or risk of AEs. This is why during patient counseling, it is not sufficient to simply tell patients to take medication with food or after meals only. We need to know whether patients are food insecure.

It is important to encourage your food-insecure patients to look for help and to implement healthy diet habits. Patients should avoid diet monotony and limit their intake of unhealthy food as much as possible. It is important to explain to patients how to read nutrition fact labels of products as well as to encourage them to introduce healthier alternatives.

Chronic stress and anxiety of food insecurity can and should be solved. It is very important to refer patients to places where they may receive help. The following links can help them find assistance in their communities.

• Local pantry and food bank locations: feedingamerica.org/find-your-local-foodbank
• Mobile food banks: feedingamerica.org/our-work/hunger-relief-programs/mobile-food-pantry-program
• Food and Nutrition Service US Department of Agriculture: fns.usda.gov/contacts/contact-map?state
• Special Supplemental Nutrition Program for Women, Infants, and Children US Department of Agriculture: fns.usda.gov/wic
• Emergency Food Assistance Program US Department of Agriculture: fns.usda.gov/tefap/emergency-food-assistance-program
• Supplemental Nutrition Assistance Program US Department of Agriculture: fns.usda.gov/snap/supplemental-nutrition-assistance-program
• National School Lunch Program US Department of Agriculture: fns.usda.gov/nslp
• School Breakfast Program US Department of Agriculture: fns.usda.gov/sbp/school-breakfast-program
• Kids Cafe Program: threesquare.org/learn/programs/childhood-nutrition/kids-cafe
• BackPack Program: feedingamerica.org/our-work/hunger-relief-programs/backpack-program
• Summer Food Service Program: feedingamerica.org/our-work/hunger-relief-programs/summer-food-service-program
• Disaster Food Assistance: feedingamerica.org/our-work/disaster-food-assistance
• Finding Food 211: 211.org/get-help/finding-foo
• Seniors Farmers' Market Nutrition Program US Department of Agriculture: fns.usda.gov/sfmnp/senior-farmers-market-nutrition-program
• Commodity Supplemental Food Program US Department of Agriculture: fns.usda.gov/csfp/commodity-supplemental-food-program
• The National Produce Prescription Collaborative: nationalproduceprescription.org
• WholeSome Wave Rx: wholesomewave.org

As pharmacy professionals, we are responsible for advocating and educating our peers how to address food insecurity and its root causes to improve our patient’s health outcomes as well as to prevent adverse drug reactions related to food insecurity.

References

1. Feeding America. The Impact of the Coronavirus on Food Insecurity in 2020 & 2021. March, 2021. Accessed December 10, 2021. https://www.feedingamerica.org/sites/default/files/2021-03/National%20Projections%20Brief_3.9.2021_0.pdf
2. Zaliak JP, Gundersen C. 2014. The health consequences of senior hunger in the United States: Evidence from the 1999-2010 NHANES. August 16, 2017. Accessed December 10, 2021. https://www.feedingamerica.org/sites/default/files/research/senior-hunger-research/senior-health-consequences-2014.pdf
3. Feeding America. Hunger in America 2014 National Report. August 2014. Accessed December 10, 2021. http://help.feedingamerica.org/HungerInAmerica/hunger-in-america-2014-full-report.pdf
4. Feeding America. Addressing food insecurity in health care settings. Hunger and Health. October 7, 2019. Accessed December 10, 2021. https://hungerandhealth.feedingamerica.org/explore-our-work/community-health-care-partnerships/addressing-food-insecurity-in-health-care-settings/
5. Feeding America. Causes and consequences of food insecurity. Hunger and Health. February 20, 2020. Accessed December 10, 2021. https://hungerandhealth.feedingamerica.org/understand-food-insecurity/hunger-health-101/
6. Alisha Coleman-Jensen, Matthew P. Rabbitt, Christian A. Gregory, and Anita Singh. 2021. Household Food Security in the United States in 2020, ERR-298, U.S. Department of Agriculture, Economic Research Service.
7. Cooper E, et al. An In-Clinic Food Pharmacy Addresses Very Low Food Security. Ann Fam Med. 2020;18(6)564. doi.org/10.1370/afm.2603
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9. Healthy People 2020. Food Insecurity. Accessed December 10, 2021. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/food-insecurity
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11. Ippolito MM, Lyles CR, Prendergast K, Seligman HK, Waxman E. Food insecurity and diabetes self-management among food pantry clients:Public Health Nutr. 2016;20(1):183-189. doi: 10.1017/S1368980016001786
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13. Hager ER, Quigg AM, Black MM, Coleman SM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):e26-e32. doi: 10.1542/peds.2009-3146
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15. Gucciardi E, Vahabi M, Norris N, Del Monte JP, Farnum C. The Intersection between Food Insecurity and Diabetes: A Review. Curr Nutr Rep. 2014;3(4):324-332. doi:10.1007/s13668-014-0104-4-S126,