Food Insecurity: A Key Social Determinant of Health for Older Adults

The number of older adults experiencing food insecurity—the lack of enough affordable, nutritious food to live a healthy, active lifestyle—has doubled since the turn of the century.1 In 2017, 7.9% of all US households with at least one adult aged 65 years and older experienced food insecurity, and 8.6% of households composed of an adult aged 65 years and older living alone were food insecure.2 With the number of adults aged 65 and older expected to rise from 49.2 million in 2016 to more than 73 million by 2030,3 the number of older adults living in food-insecure households will likely continue its dramatic rise in the absence of improved interventions. These demographic trends are important for clinicians because food insecurity among older adults is associated with multiple negative health outcomes. Food-insecure older adults are more likely to be in fair or poor health, with frequently associated comorbidities including diabetes, depression, hypertension, heart disease, and gingivitis.4, 5 Food-insecure older adults are also more likely to have limitations in activities of daily living.5, 6 Food insecurity and multimorbidity may create a negative feedback loop. In some cases, it is thought that food insecurity increases morbidity risk. This may be the case for conditions that are highly sensitive to diet or medication adherence because food-insecure older adults must frequently make difficult choices to afford either healthy food or medications. In other cases, it is likely that poor health increases the risk for food insecurity. Out-of-pocket healthcare expenditures associated with poor health can substantially impact the household food budget. In addition, functional impairments (physical disability, limited visual acuity, poor dentition, cognitive impairment, and social isolation) can make chronic disease self-management both more challenging and more expensive.7 Access to healthy food in this population may be further limited by challenges with transportation. As a result, clinicians may be regularly addressing the causes and consequences of food insecurity in the clinical setting, often without recognizing it or knowing how best to address it.8 Recognizing food insecurity can be especially challenging given the frequent co-occurrence of food insecurity and obesity in the United States because dietary intake in food-insecure households frequently shifts away from healthier, more expensive foods and toward cheaper foods that are typically more obesogenic. There is good evidence, however, that programs supporting food security can improve health outcomes and the likelihood of aging in place among older adults, suggesting that clinical interventions are warranted. For example, participation in the Supplemental Nutrition Assistance Program (SNAP), the largest food support system in the United States, is associated with reductions in avoidable healthcare utilization including nursing home stays, hospitalizations, and emergency department visits.9, 10 SNAP participation is also associated with reductions in cost-related medication nonadherence among food-insecure older adults.11 Although food insecurity poses challenges for maintaining health and preventing chronic disease complications, the frequency with which many older adults interact with the health system provides opportunities for integrating discussions about health needs, food security, and community resources for food and nutrition. Food insecurity may at times be addressed as part of routine clinical care. For example, a frail homebound older adult may present as malnourished and be referred for home-delivered meals, incidentally addressing the patient's food insecurity through treatment of a medical condition. Other times, lack of recognition of food insecurity may hamper clinical care. For instance, a clinician treating an older adult with diabetes experiencing frequent episodes of hypoglycemia may respond first by reducing medication doses, rather than uncovering that the root cause of the hypoglycemia is an inability to afford food, a barrier that could be better addressed by referral to a food and nutrition support program. Intervene clinically: Clinicians and practice teams should become familiar with and refer food-insecure patients to publicly or privately funded nutrition programs known to support food security (Table 1), ideally by creating systems that make such referrals time efficient. Such programs include SNAP, congregate meals, and home-delivered meals, all of which are supported to some extent by federal funding. In addition to supporting food security and improved dietary intake, these programs are associated with reductions in isolation, depression, preventable healthcare utilization, and healthcare costs.9, 10, 14-16 Underenrollment in SNAP is of particular concern for older adults. Fewer than half of eligible older adults participate in SNAP, despite its proven health benefits and entitlement structure.17 Common barriers to SNAP participation among older adults include cumbersome state or local application processes, misunderstanding of program benefits, lack of eligibility awareness, and stigma.18 Clinicians and health systems are in a unique position to address many of these barriers, such as reframing food assistance as a benefit that can support health and independence. Table 2 provides examples of specific clinical strategies and policy solutions related to these opportunities. In addition, the Food Research www.frac.org) and the AARP Foundation (www.aarp.org/aarp-foundation) provide numerous resources and tools for local, state, and federal advocacy efforts focused on food insecurity and poverty among older adults. Clinical strategies Policy solutions Clinical strategies Policy solutions Clinical strategies Policy solutions Clinical programs and systems to screen for and intervene on food insecurity are being scaled across the United States. A 2017 review identified 22 healthcare entities that have implemented systematic food-insecurity screening programs for older adults.21 Kaiser Permanente Colorado and Hunger Free Colorado, for instance, entered into a partnership in 2011, leveraging their unique assets to screen patients for food insecurity during clinical visits, refer food-insecure patients to community specialists with expertise in community and federal nutrition programs, and support enrollment in appropriate programming.22 Other clinical systems have adopted on-site solutions. For example, ProMedica health system has screened all patients for food insecurity since 2015. In the primary care setting, food-insecure patients are referred to an on-site Food Pharmacy. In the inpatient setting, patients are provided with emergency food at hospital discharge, if needed.20, 23 Food security is important for the physical and mental health of older adults. Clinicians can address food insecurity among older adults by systematically screening patients for food insecurity, intervening when a food-insecure patient is identified to establish a connection with a program supporting food security, and advocating for policies, programs, and practices that reduce food insecurity among older adults. We acknowledge these NOPREN members who participated in developing this editorial: Sandra Stenmark, MD, Kaiser Permanente, Colorado, and Sanjana Marpadga, MSc, UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center. Neither one of these individuals was compensated for their contributions. Conflicts of Interest: The authors have no financial, personal, or other conflicts of interest to disclose. Author Contributions: Jennifer Pooler, Heather Hartline-Grafton, Marydale DeBor, and Hilary K. Seligman conceptualized the article, and all authors contributed to writing and editing the content. Funding information: The authors of this publication are members of the Food Security working group, part of the Nutrition and Obesity Policy Research and Evaluation Network (NOPREN). NOPREN is supported by Cooperative Agreement no. 5U48DP00498-05 from the Centers for Disease Control and Prevention, Prevention Research Centers Program. Dr. Sudore is funded in part by a National Institutes of Health, National Institute on Aging K24AG054415 award. The findings in this publication are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or NIH. Sponsor's Role: Not applicable.