Food insecurity: what does it mean to people with diabetes?

Access to sufficient, nutritious food is generally accepted as one of the basic rights for mankind, and yet, in today's economic crisis (and for the first time since the 1970s), over one billion people worldwide are undernourished.1 Food insecurity ranges from famine at one end of the spectrum to restrictions in access to good quality diets at the other. Food security was first defined at the Rome World Food Summit in 1996 as a state ‘when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life’, and led to the Rome declaration calling for a significant reduction in numbers of undernourished people in United Nations member states by 2015.2 This target was also included in the Millennium Development Goals, where the aim was a 50% reduction in undernourished people by 2015,3 but recent events including natural disasters (earthquakes, tsunamis, floods and drought) and those that are man-made (wars and civil conflict, agricultural and economic policies) have conspired to increase, rather than reduce, food insecurity and its associated undernourishment. Food insecurity in its most severe form is typically associated with disasters such as earthquakes, tsunamis, floods, droughts and war and, although these events make the headlines and are often associated with appeals for relief, the fact remains that over 90% of food insecurity is inextricably linked to chronic poverty.4 Those most affected by food insecurity are the most vulnerable in society and include large segments of the population in low and middle-income countries (LMICs). There is no agreed international standard for the measurement of food insecurity, and measurements range from those conducted at the global and national level using food availability data to those assessing risk at the individual or household level.5 Data derived from national food availability statistics are widely quoted as they are cheap and relatively easy to collect, but do not provide meaningful information about inequalities in food provision within populations. Measuring food insecurity at the individual or household level requires more resources, but does provide data about those most at risk and can help influence priorities for interventions. Professor Rafael Pérez-Escamilla at Yale University has developed a measurement tool adapted from the US Household Food Security Survey Model that has been validated successfully in Brazil, where it is now used in nationwide surveys.6 The Food and Agriculture Organisation of the United Nations (FAO) has offered support for the development of this tool with the aim of standardising food insecurity measures around the globe. The lack of an agreed international standard for measuring food insecurity makes comparisons between different countries difficult. Undernourishment estimates published by the FAO are derived from national data from food-balance sheets and the latest figures suggest that over one billion of the world's population have insufficient dietary energy intake. At the national level, the prevalence of undernourishment ranges from 70% in some parts of Sub-Saharan Africa to <5% in high-income countries.1 In addition, over two billion people have micronutrient deficiencies, including iodine, iron, Vitamin A and zinc.7 Household and individual surveys in LMICs have shown that in India more than one-third of the population live below the poverty line and 50% of children are malnourished,8 and a small study from Vellore reported that 75% of households were food insecure.9 In China, a national survey reported that in 2007 just under five million people lived below the poverty line and 11% of the population were malnourished.10 Studies from South Africa show that although rates of those reporting hunger have improved, only 48% of households are food secure,11 and in deprived areas of Africa such as the slums in Nigeria, hunger is common and just 20% of households are food secure.12 The Oxford Health Alliance, a charity devoted to preventing non-communicable disease (NCD), has been facilitating a study investigating Community Interventions for Health (CIH) in various LMICs and has reported food insecurity prevalence rates of 0.5% in Hangzhou city, China, 14.8% in Kerala State, India, and 14.3% in Mexico City (personal communication). Although food insecurity affects LMICs disproportionately, its prevalence in high-income countries is increased among vulnerable groups. In the US in 2009 for example, 14.5% of households were food insecure, but this increased to 37% of households comprising single mothers and children, 25% of black households and 27% of Hispanic households.13 In Australia, food insecurity is low and affects just 5% of the population, but much higher values are reported for the unemployed (23%) and single parent households (23%).14 In the UK, food insecurity is not routinely measured, but is known to be high in vulnerable groups. A recent study among Sure Start households, for example, showed that 20% of women live in food insecure households and that food insecurity is associated with poor quality of diet.15 Why does food insecurity matter? Studies have shown that food insecurity is associated with adverse health effects in both children and adults; children who are exposed to food insecurity have higher rates of infectious disease, chronic illness, nutrient deficiencies including iron-deficiency anaemia, and mental health and behavioural problems.16 In adults, food insecurity is strongly associated with mental health problems and with NCDs including coronary heart disease, diabetes and hypertension.17 Although food insecurity is more commonly associated with frank malnutrition in LMICs, it does have enormous health implications in higher-income countries such as the US.18 The cynical among us may suggest that food insecurity is a good thing and that in many societies today, where obesity and obesity-related disease are reaching epidemic proportions, restrictions on access to food may be of benefit. However, one of the distinct characteristics of limited access to food is a feature known as the food insecurity-obesity paradox, where obesity rates are higher in those who are food insecure. This paradox is explained by the fact that those who are food insecure have restricted funds and rely on cheap, nutrient-poor, energy-dense foods rather than nutrient-dense, expensive foods like lean meat, fish, vegetables and fruit. Poverty is associated with overconsumption of foods such as fats and oils, refined grains and potatoes, as they represent the lowest cost options.19 Women appear to be more at risk of obesity than men, with the risk estimated to be 20–40% higher for food insecure women,20 and a BMI, after correcting for variables, that is on average 0.9kg/m2 higher than that of food secure women.21 Food insecurity has been identified as an independent risk factor for the development of type 2 diabetes,22 for poor glycaemic control in established diabetes,23 for increased rates of hypoglycaemia,24 and for reduced health-related quality of life in people with type 2 diabetes.25 In many higher income countries, rates of obesity and type 2 diabetes follow a socio-economic gradient, with higher prevalence among the most disadvantaged and vulnerable groups in society: the poor, the unemployed and black and ethnic minority groups. These are also the groups most affected by food insecurity. Why does food insecurity affect glycaemic control? Firstly, access to sufficient food can help prevent hypoglycaemia, and several studies have reported that food insecurity increases the risk of hypoglycaemia with one study in the US stating that 31% of hypoglycaemic reactions were attributable to the inability to afford sufficient food.26 A healthy diet is fundamental to the successful management of diabetes, and is recommended by international consensus. The nutritional components of diets recommended for diabetes are those that are most compromised in the food insecure household, namely lean meat, fish, wholegrains, fruit and vegetables. Food insecurity among people with diabetes is characterised by lack of food choice, poor quality food, unbalanced diets, missing meals and high intakes of high-fat, high-sugar foods.25 In addition, poverty directly affects access to health care and medication, especially in countries where medical care is not provided by the state, and further reductions are made in expenditure on food in order to buy necessary medication. This vicious circle further affects diabetes control, as those who are food insecure and have poor glycaemic control will require more medication, and so more resources are allocated for medicine, and this exacerbates food insecurity. Reducing poverty will automatically improve food security, especially among the most vulnerable as they spend a greater proportion of their budget on food. Many higher income countries have food assistance programmes in place to help those who are food insecure; for example, food stamps in the US, free school meals in the UK and breakfast clubs in Australia. Many of these programmes are directed at children and there is evidence that school-based feeding programmes have a significantly positive effect on health and well-being.27 In people with diabetes, health professionals can help to identify food insecurity by asking questions about access to food and use of food assistance programmes. Dietitians can help by formulation advice specifically about achieving a healthy diet in a cost-effective way. Until recently, food insecurity has been a largely invisible problem among people with diabetes although it has a profound effect upon health and quality of life. Changes at the societal level, including adequate funding to support and promote economic self-sufficiency and increased use of food assistance programmes, will improve food security. Health professionals can also improve outcomes in food insecure people with diabetes by incorporating strategies directed at those at risk into their everyday clinical practice. There are no conflicts of interest declared. References are available in Practical Diabetes online at www.practicaldiabetes.com.