&
Food insecurity food deserts Current challenges for nurse practitioners Abstract: Food insecurity has been steadily increasing in the United States with prevalence at nearly 15% of all households. Nurse practitioners can assess for food insecurity and provide local resources for families living in neighborhoods without easy access to healthy foods, otherwise known as food deserts.
urse practitioners (NPs) may be aware of hunger, malnutrition, and food insecurity in the poorest of populations. However, the presence of food insecurity may not be readily apparent. This article examines food insecurity and food deserts in the United States using a review of recent literature, a discussion of associated health considerations and health disparities, and implications for NP practice.
N
■ Source of the problem Food insecurity has been steadily increasing in the United States since it was first measured in 1995, and families may be food insecure with or without hunger.1 The U.S. Department of Agriculture (USDA) defines food security as “access by all people at all times to enough food for an active,
healthy life.”2 Food insecurity indicators include reduced food intake, disrupted eating patterns, reduced food quality, reduced variety of food, and/or reduced desirability of food.3 Food insecurity may be episodic or chronic. The most recently reported population survey of households, conducted by the Committee on National Statistics of the National Academies, indicates that as of December 2011, roughly 15% of all households were food insecure at some time during 2011, and more than 20% of households with children were food insecure.4 These figures translate into more than 50.1 million individuals in 2011 who were food insecure in the United States. Compared with the national average of 14.9%, significant rates of food insecurity were found among Black households (25.1%), Hispanic households (26.2%), low-income households with incomes less
Keywords: food desert, food insecurity, malnutrition, obesity
32 The Nurse Practitioner • Vol. 40, No. 8
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
Photo by Tetra Images / Alamy ©
By Nadine L. Camp, MSN, APRN, CPNP
Food insecurity and food deserts
than 185% of the poverty threshold (34.5%; the Federal poverty line was $22,811 for a family of four in 2011), and single-parent households with children (female [36.8%] and male [24.9%]).4 ■ Food deserts Food desert is a term that has surfaced in recent years to describe a lack of easy availability to healthy foods and is defined as “urban neighborhoods and rural towns without ready access to fresh, healthy, and affordable food.”5 The USDA, U.S. Department of the Treasury, and the U.S. Department of Health and Human Services (HHS) defined food desert as “a census tract with a substantial share of residents who live in low-income areas that have low levels of access to a grocery store or healthy, affordable food retail outlet.”5 In 2010, the USDA estimated nearly 30 million people in the United States lived in food deserts, that is, low-income neighborhoods located more than one mile from a supermarket.6 ■ Review of literature In households enduring episodes of food insecurity, changes in dietary habits are more likely to persist due to repeated shortfalls in the food budget. The result may be a reduced intake of food or an increase in inexpensive, calorie-dense, obesogenic foods and less nutrient-dense foods, such as fruits, vegetables, lean protein, and whole grains.7-9 Additionally, food-insecure individuals have described food overconsumption and consuming less desirable foods during times when their food supply is reduced or in anticipation of insecurity.1 Burkhardt et al. studied urban families receiving public benefits (n = 144) and concluded nutrition may be compromised for infants living in food-insecure families, with parents diluting or limiting infant formula to make it last.10 The regular consumption or overconsumption of calorie-dense, nutrient-deficient, low-cost foods and beverages can cause weight gain in the absence of physical activity, which has prompted several studies examining the paradoxical correlation of obesity and food insecurity. In a recent review of the literature, Franklin et al. examined 19 studies since 2005 and reported mixed results regarding age and gender groups, with a positive association among women, growing evidence of an association in adolescents, and inconsistent evidence with children.1 In another recent review, Larson and Story synthesized 42 studies for the multifaceted relationship between weight status and food insecurity in U.S. households.11 The authors noted food insecurity affected families and children who were at the highest risk for obesity due to income and racial status. However, the authors reported the evidence needed to firmly www.tnpj.com
establish an association between food insecurity and obesity was inconclusive, citing multiple studies with mixed results regarding increased prevalence of obesity among children and men living in food-insecure households.11 Mothers and infants receiving supplemental benefits (n = 201 pairs) were the subjects of a study by Gross and colleagues, and the researchers concluded maternal food insecurity was associated with an increase in controlling feeding style by the mother, hypothesized to disrupt the child’s self-regulation of satiety.12 In a summary of studies (n = 21) examining the relationship between food insecurity and overweight/ obesity in children, Eisenmann et al. provided evidence to support the coexistence and high prevalence of obesity in children and food insecurity—although not a causative association.13 There was overwhelming evidence in several studies, however, that adult women experiencing nutritional uncertainty were more likely to be obese than women who were food secure.1,8,11 Martin and Lippert examined the positive association between adult females (n = 7,931), obesity, and food insecurity.14 The authors found mothers with food insecurity were more likely to be overweight or obese compared with food insecure nonmothers for reasons not related to pregnancy. The authors suggested childrearing responsibilities as well as sustained food insecurity contributed to weight gain among this demographic group. Troy et al. reported the strong association between stress and food insecurity was complicated, and the anticipation of inadequate food for the family was a threat, causing some to overeat to seek comfort.15 There are additional health consequences to consider other than obesity that may result from food insecurity. In a study examining the association between food insecurity and clinical evidence of diet-related health problems (n = 5,094), Seligman et al. found hypertension, hyperlipidemia, poorly-controlled diabetes, and cardiovascular risk factors were significantly higher in food-insecure individuals. 7 Kim and Frongillo reported significantly higher depression scores among food-insecure older adults than their food-secure counterparts with two longitudinal data sets (n = 15,845).16 A study by Ramsey et al. (n = 505) looked at the association between food insecurity and adverse health consequences in Australia, the authors were able to demonstrate food insecurity was associated with poorer general health, increased healthcare service utilization, and depression. 9 While the evidence in the literature regarding the health effects of food insecurity on children is limited, a study by Belsky and colleagues found food insecurity had a significant association with long-term emotional problems for youth, such as anxiety and depression (n = 1,116).17 While the results of many of The Nurse Practitioner • August 2015 33
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Food insecurity and food deserts
the studies discussed lacked generalizability and identified the need for further study, the importance of these findings and the implications for health and well-being cannot be overlooked. ■ Health disparities and food insecurity NPs are familiar with health disparities, defined as “differences in health outcomes between groups that reflect social inequalities.”18 This concept can be further described as preventable differences due to unequal distribution of resources, with disadvantaged populations identified by location, race, income levels, and others.19 Food insecurity is higher among some minority racial and ethnic groups and families living in poverty. The social determinants of food insecurity should be considered in this discussion and can assist the NP when assessing contributing factors to undernutrition among patients. Healthy People 2020 is a set of goals and objectives launched by HHS aimed at improving the health of all U.S. citizens.20 Healthy People 2020 defines social determinants of health as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”21 In a systematic review of food deserts (n = 49), Beaulac and colleagues found poor access to healthy food for low-income and minority groups.22 Limited accessibility
NP an opportunity to provide optimal care with potential solutions to improve nutrition while avoiding malnutrition and obesity, which can occur when nutrient-dense foods are in limited supply. Eliciting information from patients and families regarding the condition of their housing, community, transportation, access to healthy food, and safe recreational areas should be considered when food insecurity is suspected or identified. While food insecurity is associated with poverty, patients should be queried regarding an adequate supply of food on a consistent basis, and the NP should make recommendations and referrals as indicated. Hidden factors such as divorce, job loss, or unexpected expenses can have a negative effect on food supplies and may go undetected or not discussed during an office visit.24
■ Intervention The role of the NP in provision of care includes access to resources for patients and families experiencing food insecurity. The ability to provide nutrition education about the health benefits of low-cost, high-nutrition foods through patient teaching, office posters, and handouts can improve outcomes along with using clinical nutritionists when available.25 When food-insecure patients are identified, patients can be referred to local food banks through a Food Bank Locator (feedingamerica.org/foodbank-results.aspx), Find a Food Pantry (www.foodpantries.org), or by calling The National Hunger Hotline Food insecurity indicators include reduced food toll-free at 1-866-3HUNGRY. NPs can also refer families to federal food asintake, disrupted eating patterns, reduced food sistance programs (see Federal food asquality and/or reduced food variety. sistance programs). The websites and resources identified in this article are not all-inclusive and can serve as a starting point when encountering food insecurity. included the presence of neighborhood stores that stocked The NP should consider some additional local programs an inadequate selection of healthy food, offered a larger that may be available with funding from community agenselection of unhealthy food, and charged higher prices than cies. The United Way launched 2-1-1, a free and confidential supermarket chain stores. The authors suggested intervenphone service funded through various sources that contions from local, federal, and state authorities to resolve price nects the caller with community resources, including food disparities and facilitate food market entry into low-income resources, in an effort to address health disparities.19,26 neighborhoods while encouraging local food cooperatives. Another small study (n = 37) by Freedman and Bell examThe USDA released the Food Desert Locator Tool in ined perceptions of an urban population regarding access 2011, an online map that identifies food deserts and food to healthy food and found participants’ perceptions were outlets by census tracts; this tool was recently replaced by accurate. In addition, 70% of low-income minority conthe Food Access Research Atlas and can be accessed at: venience stores had no fresh fruits or vegetables to sell.23 www.ers.usda.gov/data-products/food-access-researchatlas.aspx#.27 This can be a helpful tool for NPs to assess the neighborhoods in which their patients reside and can ■ Assessment direct the NP during the patient history component of the A thorough patient nutritional assessment and history office visit. may assist in identifying food insecurity and may offer the 34 The Nurse Practitioner • Vol. 40, No. 8
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
Food insecurity and food deserts
■ The role of the NP in the community Using the Food Access Research Atlas can facilitate assessment of the neighborhood resources and the local food environment. NPs can familiarize themselves with the economic demographics of the population by accessing data on poverty through the U.S. Census Bureau, which can provide important baseline information.28 Working to eliminate barriers for families and individuals experiencing food insecurity and ensuring patients and residents of the community have improved access to nutritious foods and experience food security is within the purview of the NP. ■ Policy implications NPs can use the information regarding food insecurity in the United States as a call-to-action by participating in community organizations to influence policy at the local level, following the example of previous initiatives, which were able to empower citizens to build relationships, plan strategically, and seek/affect change to improve a food desert environment.29 NPs can advocate for disadvantaged groups when they encounter social disparities that affect the health outcomes of the population they serve. The current administration has committed to reducing food deserts through the Healthy Food Financing Initiative with funding to support projects that improve access to healthy, affordable food in communities where these options are limited or do not exist.30 NPs can work to facilitate access to funding for such projects by partnering with community leaders and stakeholders. ■ Implications for research Further study is needed to explore the association of food insecurity, food deserts, malnutrition, and obesity. Nutritional resources exist and remain available to virtually anyone who seeks assistance. Further research is needed to determine why individuals continue to remain food insecure for extended periods of time. The relationship between food insecurity and health consequences other than obesity–particularly the long-term effects on individuals who experienced food insecurity during childhood–warrants longitudinal investigation. The health effects on populations living in food deserts, whether rural or urban, should be further examined. The mental health component cannot be overlooked, and the relationship between depression and prolonged food insecurity should be studied. REFERENCES 1. Franklin B, Jones A, Love D, Puckett S, Macklin J, White-Means S. Exploring mediators of food insecurity and obesity: a review of recent literature. J Community Health. 2012;37(1):253-264. 2. USDA. Food Security in the U.S.-Overview. Economic Research Service Website. 2013. http://www.ers.usda.gov/topics/food-nutrition-assistance/ food-security-in-the-us.aspx.
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Federal food assistance programs Federal Food Programs that provide assistance to those in need: SNAP—Supplemental Nutrition Assistance Program (Formerly known as the Food Stamp Program). This is the largest program, offering aid to millions of Americans who are low-income and eligible. Information eligibility, and application information available at www.fns.usda.gov/snap/ applicant_recipients/apply.htm. TEFAP—The Emergency Food Assistance Program—provides emergency food assistance. www.fns.usda.gov/ fdd/programs/tefap/. WIC—The Special Supplemental Nutrition Program for Women, Infants and Children—provides grants to states to assist low-income pregnant, breastfeeding mothers, non-breastfeeding postpartum mothers, infants, children under the age of 5 years. www.fns. usda.gov/wic/. FMNP—WIC Farmers’ Market Nutrition Program—available to WIC participants, the program provides fresh local produce. www.fns.usda.gov/fmnp. CSFP—Commodity Supplemental Food Program—federally funded supplemental nutrition program available to low-income pregnant, breastfeeding, and postpartum mothers, infants, children under the age of 6 years, and senior citizens over 60 years. www.fns.usda.gov/fdd/ programs/csfp/. Child Nutrition Programs—several programs available at schools and daycare centers: School Breakfast Program, Fresh Fruit and Vegetable Program, National School Lunch Program, and others. www.fns.usda.gov/childnutrition-programs. SFMNP—Seniors Farmers’ Market Nutrition Program—provides fresh local produce to lowincome seniors. www.fns.usda.gov/wic/seniorFMNP/ seniorfmnpoverview.htm
3. USDA. Definitions of Food Security. Economic Research Service Website. 2013. http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-inthe-us/definitions-of-food-security.aspx#characteristics. 4. USDA. Food Security in the U.S.-Key Statistics and Graphics. Economic Research Service Website. 2012. http://www.ers.usda.gov/topics/food-nutritionassistance/food-security-in-the-us/key-statistics-graphics.aspx. 5. USDA. Agricultural Marketing Service. Food Deserts. 2013. http://apps.ams. usda.gov/fooddeserts/foodDeserts.aspx. 6. USDA. Access to Affordable and Nutritious Food: Updated Estimates of Distance to Supermarkets Using 2010 Data. Economic Research Service Website. 2012. http://www.ers.usda.gov/publications/err-economic-research-report/err143. aspx#.UUJAWaV6ne5. 7. Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140(2):304-310. 8. Crawford PB, Webb KL. Unraveling the paradox of concurrent food insecurity and obesity. Am J Prev Med. 2011;40(2):274-275. 9. Ramsey R, Giskes K, Turrell G, Gallegos D. Food insecurity among adults residing in disadvantaged urban areas: potential health and dietary consequences. Public Health Nutr. 2012;15(2):227-237. 10. Burkhardt MC, Beck AF, Kahn RS, Klein MD. Are Our Babies Hungry? Food insecurity among infants in urban clinics. Clin Pediatr (Phila). 2012;51(3):238-243. 11. Larson NI, Story MT. Food insecurity and weight status among U.S. children and families: a review of the literature. Am J Prev Med. 2011;40(2):166-173.
The Nurse Practitioner • August 2015 35
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Food insecurity and food deserts
12. Gross RS, Mendelsohn AL, Fierman AH, Racine AD, Messito MJ. Food insecurity and obesogenic maternal infant feeding styles and practices in low-income families. Pediatrics. 2012;130(2):254-261. 13. Eisenmann JC, Gundersen C, Lohman BJ, Garasky S, Stewart SD. Is food insecurity related to overweight and obesity in children and adolescents? A summary of studies, 1995-2009. Obes Rev. 2011;12(5):e73-e83. 14. Martin MA, Lippert AM. Feeding her children, but risking her health: the intersection of gender, household food insecurity and obesity. Soc Sci Med. 2012;74(11):1754-1764.
22. Beaulac J, Kristjansson E, Cummins S. A systematic review of food deserts, 1966-2007. Prev Chronic Dis. 2009;6(3):A105. 23. Freedman DA, Bell BA. Access to healthful foods among an urban food insecure population: perceptions versus reality. J Urban Health. 2009;86(6):825-838. 24. Coleman-Jensen A, Nord M, Andrews M, Carlson S. Household food security in the United States in 2010. USDA-ERS Economic Research Report 125. 2013. http:// www.ers.usda.gov/publications/ap-administrative-publication/ap-058.aspx. 25. Kregg-Byers CM, Schlenk EA. Implications of food insecurity on global health policy and nursing practice. J Nurs Scholarsh. 2010;42(3):278-285.
15. Troy LM, Miller EA, Olson S. Setting the Stage for the Coexistence of Food Insecurity and Obesity.” Hunger and Obesity: Understanding a Food Insecurity Paradigm: Workshop Summary. Washington, DC: The National Academies Press; 2011. http://www.iom.edu/Reports/2011/Hunger-and-Obesity-Understandinga-Food-Insecurity-Paradigm.aspx.
26. 2-1-1. Frequently Asked Questions. 2013. http://www.211us.org/faq.htm.
16. Kim K, Frongillo EA. Participation in food assistance programs modifies the relation of food insecurity with weight and depression in elders. J Nutr. 2007;137(4):1005-1010.
28. United States Census Bureau. Poverty Data. Areas with Concentrated Poverty: 2006-2010. 2011. http://www.census.gov/prod/2011pubs/acsbr10-17.pdf.
17. Belsky DW, Moffitt TE, Arseneault L, Melchior M, Caspi A. Context and sequelae of food insecurity in children’s development. Am J Epidemiol. 2010;172(7):809-818. 18. Frieden TR. CDC Health Disparities and Inequities Report—United States, 2011. MMWR Morb Mortal Wkly Rep. 2011;60:1. http://www.cdc.gov/mmwr/ pdf/other/su6001.pdf. 19. Linnan LA. Research collaboration with 2-1-1 to eliminate health disparities: an introduction. Am J Prev Med. 2012;43(6 suppl 5):S415-S419.
27. USDA. Food Desert Locator. Overview. Economic Research Service Website. 2012. http://www.ers.usda.gov/data-products/food-desert-locator.aspx#.UUNCDa V6ne4.
29. Lewis LB, Galloway-Gilliam L, Flynn G, Nomachi J, Keener LC, Sloane DC. Transforming the urban food desert from the grassroots up: a model for community change. Fam Community Health. 2011;34(suppl 1):S92-S101. 30. HHS. Office of Community Services. Healthy Food Financing Initiative. 2011. http:// www.acf.hhs.gov/programs/ocs/resource/healthy-food-financing-initiative-0. Nadine L. Camp is a pediatric nurse practitioner at Children’s National Medical Center, Washington, D.C. and a doctoral candidate at The Catholic University of America, Washington, D.C.
20. HHS. Healthy People 2020. HealthyPeople.gov Website. 2010. http://www. healthypeople.gov/2020/TopicsObjectives2020/pdfs/HP2020_brochure_ with_LHI_508.pdf.
The author would like to thank Dr. Eden Kan from the Catholic University of America for her guidance and support in writing this article.
21. HHS. Social Determinants of Health. HealthyPeople.gov Website. 2012. http://www.healthypeople.gov/2020/topicsobjectives2020/overview. aspx?topicid=39.
The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NPR.0000453644.36533.3a
36 The Nurse Practitioner • Vol. 40, No. 8
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
Food insecurity food deserts Current challenges for nurse practitioners Abstract: Food insecurity has been steadily increasing in the United States with prevalence at nearly 15% of all households. Nurse practitioners can assess for food insecurity and provide local resources for families living in neighborhoods without easy access to healthy foods, otherwise known as food deserts.
urse practitioners (NPs) may be aware of hunger, malnutrition, and food insecurity in the poorest of populations. However, the presence of food insecurity may not be readily apparent. This article examines food insecurity and food deserts in the United States using a review of recent literature, a discussion of associated health considerations and health disparities, and implications for NP practice.
N
■ Source of the problem Food insecurity has been steadily increasing in the United States since it was first measured in 1995, and families may be food insecure with or without hunger.1 The U.S. Department of Agriculture (USDA) defines food security as “access by all people at all times to enough food for an active,
healthy life.”2 Food insecurity indicators include reduced food intake, disrupted eating patterns, reduced food quality, reduced variety of food, and/or reduced desirability of food.3 Food insecurity may be episodic or chronic. The most recently reported population survey of households, conducted by the Committee on National Statistics of the National Academies, indicates that as of December 2011, roughly 15% of all households were food insecure at some time during 2011, and more than 20% of households with children were food insecure.4 These figures translate into more than 50.1 million individuals in 2011 who were food insecure in the United States. Compared with the national average of 14.9%, significant rates of food insecurity were found among Black households (25.1%), Hispanic households (26.2%), low-income households with incomes less
Keywords: food desert, food insecurity, malnutrition, obesity
32 The Nurse Practitioner • Vol. 40, No. 8
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
Photo by Tetra Images / Alamy ©
By Nadine L. Camp, MSN, APRN, CPNP
Food insecurity and food deserts
than 185% of the poverty threshold (34.5%; the Federal poverty line was $22,811 for a family of four in 2011), and single-parent households with children (female [36.8%] and male [24.9%]).4 ■ Food deserts Food desert is a term that has surfaced in recent years to describe a lack of easy availability to healthy foods and is defined as “urban neighborhoods and rural towns without ready access to fresh, healthy, and affordable food.”5 The USDA, U.S. Department of the Treasury, and the U.S. Department of Health and Human Services (HHS) defined food desert as “a census tract with a substantial share of residents who live in low-income areas that have low levels of access to a grocery store or healthy, affordable food retail outlet.”5 In 2010, the USDA estimated nearly 30 million people in the United States lived in food deserts, that is, low-income neighborhoods located more than one mile from a supermarket.6 ■ Review of literature In households enduring episodes of food insecurity, changes in dietary habits are more likely to persist due to repeated shortfalls in the food budget. The result may be a reduced intake of food or an increase in inexpensive, calorie-dense, obesogenic foods and less nutrient-dense foods, such as fruits, vegetables, lean protein, and whole grains.7-9 Additionally, food-insecure individuals have described food overconsumption and consuming less desirable foods during times when their food supply is reduced or in anticipation of insecurity.1 Burkhardt et al. studied urban families receiving public benefits (n = 144) and concluded nutrition may be compromised for infants living in food-insecure families, with parents diluting or limiting infant formula to make it last.10 The regular consumption or overconsumption of calorie-dense, nutrient-deficient, low-cost foods and beverages can cause weight gain in the absence of physical activity, which has prompted several studies examining the paradoxical correlation of obesity and food insecurity. In a recent review of the literature, Franklin et al. examined 19 studies since 2005 and reported mixed results regarding age and gender groups, with a positive association among women, growing evidence of an association in adolescents, and inconsistent evidence with children.1 In another recent review, Larson and Story synthesized 42 studies for the multifaceted relationship between weight status and food insecurity in U.S. households.11 The authors noted food insecurity affected families and children who were at the highest risk for obesity due to income and racial status. However, the authors reported the evidence needed to firmly www.tnpj.com
establish an association between food insecurity and obesity was inconclusive, citing multiple studies with mixed results regarding increased prevalence of obesity among children and men living in food-insecure households.11 Mothers and infants receiving supplemental benefits (n = 201 pairs) were the subjects of a study by Gross and colleagues, and the researchers concluded maternal food insecurity was associated with an increase in controlling feeding style by the mother, hypothesized to disrupt the child’s self-regulation of satiety.12 In a summary of studies (n = 21) examining the relationship between food insecurity and overweight/ obesity in children, Eisenmann et al. provided evidence to support the coexistence and high prevalence of obesity in children and food insecurity—although not a causative association.13 There was overwhelming evidence in several studies, however, that adult women experiencing nutritional uncertainty were more likely to be obese than women who were food secure.1,8,11 Martin and Lippert examined the positive association between adult females (n = 7,931), obesity, and food insecurity.14 The authors found mothers with food insecurity were more likely to be overweight or obese compared with food insecure nonmothers for reasons not related to pregnancy. The authors suggested childrearing responsibilities as well as sustained food insecurity contributed to weight gain among this demographic group. Troy et al. reported the strong association between stress and food insecurity was complicated, and the anticipation of inadequate food for the family was a threat, causing some to overeat to seek comfort.15 There are additional health consequences to consider other than obesity that may result from food insecurity. In a study examining the association between food insecurity and clinical evidence of diet-related health problems (n = 5,094), Seligman et al. found hypertension, hyperlipidemia, poorly-controlled diabetes, and cardiovascular risk factors were significantly higher in food-insecure individuals. 7 Kim and Frongillo reported significantly higher depression scores among food-insecure older adults than their food-secure counterparts with two longitudinal data sets (n = 15,845).16 A study by Ramsey et al. (n = 505) looked at the association between food insecurity and adverse health consequences in Australia, the authors were able to demonstrate food insecurity was associated with poorer general health, increased healthcare service utilization, and depression. 9 While the evidence in the literature regarding the health effects of food insecurity on children is limited, a study by Belsky and colleagues found food insecurity had a significant association with long-term emotional problems for youth, such as anxiety and depression (n = 1,116).17 While the results of many of The Nurse Practitioner • August 2015 33
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Food insecurity and food deserts
the studies discussed lacked generalizability and identified the need for further study, the importance of these findings and the implications for health and well-being cannot be overlooked. ■ Health disparities and food insecurity NPs are familiar with health disparities, defined as “differences in health outcomes between groups that reflect social inequalities.”18 This concept can be further described as preventable differences due to unequal distribution of resources, with disadvantaged populations identified by location, race, income levels, and others.19 Food insecurity is higher among some minority racial and ethnic groups and families living in poverty. The social determinants of food insecurity should be considered in this discussion and can assist the NP when assessing contributing factors to undernutrition among patients. Healthy People 2020 is a set of goals and objectives launched by HHS aimed at improving the health of all U.S. citizens.20 Healthy People 2020 defines social determinants of health as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”21 In a systematic review of food deserts (n = 49), Beaulac and colleagues found poor access to healthy food for low-income and minority groups.22 Limited accessibility
NP an opportunity to provide optimal care with potential solutions to improve nutrition while avoiding malnutrition and obesity, which can occur when nutrient-dense foods are in limited supply. Eliciting information from patients and families regarding the condition of their housing, community, transportation, access to healthy food, and safe recreational areas should be considered when food insecurity is suspected or identified. While food insecurity is associated with poverty, patients should be queried regarding an adequate supply of food on a consistent basis, and the NP should make recommendations and referrals as indicated. Hidden factors such as divorce, job loss, or unexpected expenses can have a negative effect on food supplies and may go undetected or not discussed during an office visit.24
■ Intervention The role of the NP in provision of care includes access to resources for patients and families experiencing food insecurity. The ability to provide nutrition education about the health benefits of low-cost, high-nutrition foods through patient teaching, office posters, and handouts can improve outcomes along with using clinical nutritionists when available.25 When food-insecure patients are identified, patients can be referred to local food banks through a Food Bank Locator (feedingamerica.org/foodbank-results.aspx), Find a Food Pantry (www.foodpantries.org), or by calling The National Hunger Hotline Food insecurity indicators include reduced food toll-free at 1-866-3HUNGRY. NPs can also refer families to federal food asintake, disrupted eating patterns, reduced food sistance programs (see Federal food asquality and/or reduced food variety. sistance programs). The websites and resources identified in this article are not all-inclusive and can serve as a starting point when encountering food insecurity. included the presence of neighborhood stores that stocked The NP should consider some additional local programs an inadequate selection of healthy food, offered a larger that may be available with funding from community agenselection of unhealthy food, and charged higher prices than cies. The United Way launched 2-1-1, a free and confidential supermarket chain stores. The authors suggested intervenphone service funded through various sources that contions from local, federal, and state authorities to resolve price nects the caller with community resources, including food disparities and facilitate food market entry into low-income resources, in an effort to address health disparities.19,26 neighborhoods while encouraging local food cooperatives. Another small study (n = 37) by Freedman and Bell examThe USDA released the Food Desert Locator Tool in ined perceptions of an urban population regarding access 2011, an online map that identifies food deserts and food to healthy food and found participants’ perceptions were outlets by census tracts; this tool was recently replaced by accurate. In addition, 70% of low-income minority conthe Food Access Research Atlas and can be accessed at: venience stores had no fresh fruits or vegetables to sell.23 www.ers.usda.gov/data-products/food-access-researchatlas.aspx#.27 This can be a helpful tool for NPs to assess the neighborhoods in which their patients reside and can ■ Assessment direct the NP during the patient history component of the A thorough patient nutritional assessment and history office visit. may assist in identifying food insecurity and may offer the 34 The Nurse Practitioner • Vol. 40, No. 8
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
Food insecurity and food deserts
■ The role of the NP in the community Using the Food Access Research Atlas can facilitate assessment of the neighborhood resources and the local food environment. NPs can familiarize themselves with the economic demographics of the population by accessing data on poverty through the U.S. Census Bureau, which can provide important baseline information.28 Working to eliminate barriers for families and individuals experiencing food insecurity and ensuring patients and residents of the community have improved access to nutritious foods and experience food security is within the purview of the NP. ■ Policy implications NPs can use the information regarding food insecurity in the United States as a call-to-action by participating in community organizations to influence policy at the local level, following the example of previous initiatives, which were able to empower citizens to build relationships, plan strategically, and seek/affect change to improve a food desert environment.29 NPs can advocate for disadvantaged groups when they encounter social disparities that affect the health outcomes of the population they serve. The current administration has committed to reducing food deserts through the Healthy Food Financing Initiative with funding to support projects that improve access to healthy, affordable food in communities where these options are limited or do not exist.30 NPs can work to facilitate access to funding for such projects by partnering with community leaders and stakeholders. ■ Implications for research Further study is needed to explore the association of food insecurity, food deserts, malnutrition, and obesity. Nutritional resources exist and remain available to virtually anyone who seeks assistance. Further research is needed to determine why individuals continue to remain food insecure for extended periods of time. The relationship between food insecurity and health consequences other than obesity–particularly the long-term effects on individuals who experienced food insecurity during childhood–warrants longitudinal investigation. The health effects on populations living in food deserts, whether rural or urban, should be further examined. The mental health component cannot be overlooked, and the relationship between depression and prolonged food insecurity should be studied. REFERENCES 1. Franklin B, Jones A, Love D, Puckett S, Macklin J, White-Means S. Exploring mediators of food insecurity and obesity: a review of recent literature. J Community Health. 2012;37(1):253-264. 2. USDA. Food Security in the U.S.-Overview. Economic Research Service Website. 2013. http://www.ers.usda.gov/topics/food-nutrition-assistance/ food-security-in-the-us.aspx.
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Federal food assistance programs Federal Food Programs that provide assistance to those in need: SNAP—Supplemental Nutrition Assistance Program (Formerly known as the Food Stamp Program). This is the largest program, offering aid to millions of Americans who are low-income and eligible. Information eligibility, and application information available at www.fns.usda.gov/snap/ applicant_recipients/apply.htm. TEFAP—The Emergency Food Assistance Program—provides emergency food assistance. www.fns.usda.gov/ fdd/programs/tefap/. WIC—The Special Supplemental Nutrition Program for Women, Infants and Children—provides grants to states to assist low-income pregnant, breastfeeding mothers, non-breastfeeding postpartum mothers, infants, children under the age of 5 years. www.fns. usda.gov/wic/. FMNP—WIC Farmers’ Market Nutrition Program—available to WIC participants, the program provides fresh local produce. www.fns.usda.gov/fmnp. CSFP—Commodity Supplemental Food Program—federally funded supplemental nutrition program available to low-income pregnant, breastfeeding, and postpartum mothers, infants, children under the age of 6 years, and senior citizens over 60 years. www.fns.usda.gov/fdd/ programs/csfp/. Child Nutrition Programs—several programs available at schools and daycare centers: School Breakfast Program, Fresh Fruit and Vegetable Program, National School Lunch Program, and others. www.fns.usda.gov/childnutrition-programs. SFMNP—Seniors Farmers’ Market Nutrition Program—provides fresh local produce to lowincome seniors. www.fns.usda.gov/wic/seniorFMNP/ seniorfmnpoverview.htm
3. USDA. Definitions of Food Security. Economic Research Service Website. 2013. http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-inthe-us/definitions-of-food-security.aspx#characteristics. 4. USDA. Food Security in the U.S.-Key Statistics and Graphics. Economic Research Service Website. 2012. http://www.ers.usda.gov/topics/food-nutritionassistance/food-security-in-the-us/key-statistics-graphics.aspx. 5. USDA. Agricultural Marketing Service. Food Deserts. 2013. http://apps.ams. usda.gov/fooddeserts/foodDeserts.aspx. 6. USDA. Access to Affordable and Nutritious Food: Updated Estimates of Distance to Supermarkets Using 2010 Data. Economic Research Service Website. 2012. http://www.ers.usda.gov/publications/err-economic-research-report/err143. aspx#.UUJAWaV6ne5. 7. Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140(2):304-310. 8. Crawford PB, Webb KL. Unraveling the paradox of concurrent food insecurity and obesity. Am J Prev Med. 2011;40(2):274-275. 9. Ramsey R, Giskes K, Turrell G, Gallegos D. Food insecurity among adults residing in disadvantaged urban areas: potential health and dietary consequences. Public Health Nutr. 2012;15(2):227-237. 10. Burkhardt MC, Beck AF, Kahn RS, Klein MD. Are Our Babies Hungry? Food insecurity among infants in urban clinics. Clin Pediatr (Phila). 2012;51(3):238-243. 11. Larson NI, Story MT. Food insecurity and weight status among U.S. children and families: a review of the literature. Am J Prev Med. 2011;40(2):166-173.
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Food insecurity and food deserts
12. Gross RS, Mendelsohn AL, Fierman AH, Racine AD, Messito MJ. Food insecurity and obesogenic maternal infant feeding styles and practices in low-income families. Pediatrics. 2012;130(2):254-261. 13. Eisenmann JC, Gundersen C, Lohman BJ, Garasky S, Stewart SD. Is food insecurity related to overweight and obesity in children and adolescents? A summary of studies, 1995-2009. Obes Rev. 2011;12(5):e73-e83. 14. Martin MA, Lippert AM. Feeding her children, but risking her health: the intersection of gender, household food insecurity and obesity. Soc Sci Med. 2012;74(11):1754-1764.
22. Beaulac J, Kristjansson E, Cummins S. A systematic review of food deserts, 1966-2007. Prev Chronic Dis. 2009;6(3):A105. 23. Freedman DA, Bell BA. Access to healthful foods among an urban food insecure population: perceptions versus reality. J Urban Health. 2009;86(6):825-838. 24. Coleman-Jensen A, Nord M, Andrews M, Carlson S. Household food security in the United States in 2010. USDA-ERS Economic Research Report 125. 2013. http:// www.ers.usda.gov/publications/ap-administrative-publication/ap-058.aspx. 25. Kregg-Byers CM, Schlenk EA. Implications of food insecurity on global health policy and nursing practice. J Nurs Scholarsh. 2010;42(3):278-285.
15. Troy LM, Miller EA, Olson S. Setting the Stage for the Coexistence of Food Insecurity and Obesity.” Hunger and Obesity: Understanding a Food Insecurity Paradigm: Workshop Summary. Washington, DC: The National Academies Press; 2011. http://www.iom.edu/Reports/2011/Hunger-and-Obesity-Understandinga-Food-Insecurity-Paradigm.aspx.
26. 2-1-1. Frequently Asked Questions. 2013. http://www.211us.org/faq.htm.
16. Kim K, Frongillo EA. Participation in food assistance programs modifies the relation of food insecurity with weight and depression in elders. J Nutr. 2007;137(4):1005-1010.
28. United States Census Bureau. Poverty Data. Areas with Concentrated Poverty: 2006-2010. 2011. http://www.census.gov/prod/2011pubs/acsbr10-17.pdf.
17. Belsky DW, Moffitt TE, Arseneault L, Melchior M, Caspi A. Context and sequelae of food insecurity in children’s development. Am J Epidemiol. 2010;172(7):809-818. 18. Frieden TR. CDC Health Disparities and Inequities Report—United States, 2011. MMWR Morb Mortal Wkly Rep. 2011;60:1. http://www.cdc.gov/mmwr/ pdf/other/su6001.pdf. 19. Linnan LA. Research collaboration with 2-1-1 to eliminate health disparities: an introduction. Am J Prev Med. 2012;43(6 suppl 5):S415-S419.
27. USDA. Food Desert Locator. Overview. Economic Research Service Website. 2012. http://www.ers.usda.gov/data-products/food-desert-locator.aspx#.UUNCDa V6ne4.
29. Lewis LB, Galloway-Gilliam L, Flynn G, Nomachi J, Keener LC, Sloane DC. Transforming the urban food desert from the grassroots up: a model for community change. Fam Community Health. 2011;34(suppl 1):S92-S101. 30. HHS. Office of Community Services. Healthy Food Financing Initiative. 2011. http:// www.acf.hhs.gov/programs/ocs/resource/healthy-food-financing-initiative-0. Nadine L. Camp is a pediatric nurse practitioner at Children’s National Medical Center, Washington, D.C. and a doctoral candidate at The Catholic University of America, Washington, D.C.
20. HHS. Healthy People 2020. HealthyPeople.gov Website. 2010. http://www. healthypeople.gov/2020/TopicsObjectives2020/pdfs/HP2020_brochure_ with_LHI_508.pdf.
The author would like to thank Dr. Eden Kan from the Catholic University of America for her guidance and support in writing this article.
21. HHS. Social Determinants of Health. HealthyPeople.gov Website. 2012. http://www.healthypeople.gov/2020/topicsobjectives2020/overview. aspx?topicid=39.
The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NPR.0000453644.36533.3a
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