1.27: Only a mirage- searching for healthy options in a food desert
Introduction
Food insecurity is defined by the United States Department of Agriculture (USDA) as “ a lack of consistent access to enough food for an active, healthy life .” 1 There are various patterns of food insecurity, and it may impact patients uniquely and intermittently. The SEARCH mnemonic ( S creen, E ducate, A djust, R ecognize, C onnect, H elp) is one way to ascertain who may be experiencing food insecurity and ensuring appropriate steps are taken to address the issue. 2
One driver of food insecurity may be socioeconomic status and limited ability to purchase healthy or fresh foods. A validated two-item screening tool may be used to ascertain whether a patient is impacted by this type of food insecurity: (1) within the past 12 months we worried whether our food would run out before we got money to buy more, or (2) within the past 12 months the food we bought just didn’t last, and we didn’t have money to get more. 2 If the patient responds with an affirmative answer to either of these questions, further exploration about the patient’s circumstances is necessary.
Another contributing factor to food insecurity is living in a food desert. The term “food desert” is a term used today that was adapted from the United Kingdom to reference neighborhoods that are deprived of food due to expenses and unavailability. 3,4 A food desert is defined as “ a geographic area, typically at the neighborhood scale or greater, in which residents experience physical and economic access barriers to affordable and healthful food procurement .” 5 In the Food, Conservation, and Energy Act, the USDA was directed to assess areas in the nation where Americans had limited access to food that was affordable and healthy. It was concluded that 23.5 million people live in low-income locations greater than one mile from a large grocery store or supermarket, with 11.5 million of these people qualifying as low-income themselves. 6,7
Households of low income and ethnic minorities rely heavily on the food environment in their immediate neighborhood. 8 Inadequacies such as transportation and socioeconomic status limit individuals to having their foods supplied by a convenience store or retailer in which food options are packaged and non-perishable, compromising the nutritional value. 5 Living in a food desert is a social determinant of health (SDH/SDOH) and is linked to higher incidences of obesity, diabetes, and cardiovascular disease due to limited fruit and vegetable consumption. 9 Diets consisting of foods that are highly processed, energy-dense, and nutrient poor are prevalent in low-income neighborhoods where fast food restaurants are bountiful, yet grocery stores with high-quality, fresh, healthy foods are scarce. 10
Income segregation also plays a large role in both the purchasing decisions of consumers and the profit-maximization of grocery stores. Profits for grocery stores are maximized when located in wealthier neighborhoods; consequently, grocery stores may locate further away from poor neighborhoods. Stores located in poor neighborhoods may not prioritize stocking healthy foods. Therefore, low-income families may need to travel further to have access to fresh, unprocessed, nutritional foods. 11 Patients in food deserts either resort to consuming sub-optimal foods due to availability or must spend extra time and money commuting to the nearest grocery store. This cycle may directly contribute to poor health outcomes because of having to settle for what food is available within close proximity. It may also contribute indirectly by choosing to spend extra money on healthy foods, which may result in less money remaining for other resources. Purchasing prescriptions or scheduling routine check-up appointments may lose prioritization when there are insufficient funds remaining to prevent and properly manage chronic disease states. 12
Case
You are a pharmacist practicing in a family medicine ambulatory care clinic
CC: “I am here for a follow-up appointment.”
Patient: TM is a 66-year-old African American male (68 in, 95kg) who presents to the office for his T2DM management follow up with the clinical pharmacist.
PMH: T2DM; gout; HLD; HTN; peripheral vascular disease; urinary retention; seizures
FH:
- Mother, father, brother, and grandparents: deceased due to cardiac history
- Brother: kidney cancer
SH:
- Former smoker (quit three years ago); 60 pack years (1.5 packs per day for 40 years)
- Former alcohol use (quit three years ago)
- Denies illicit drug use
Allergies: Penicillin (rash)
V itals:
- BP 123/75 mmHg
- HR 76 bpm
- RR 16/min
- Temp 98.6°F
- Pulse ox 96% on RA
Labs:
| Parameter | Value | Parameter | Value |
|---|---|---|---|
| Na | 142 mmol/L | AST | 10 U/L |
| K | 4.5 mmol/L | ALT | 13 U/L |
| Cl | 100 mmol/L | LDL | 71 mg/dL |
| CO 2 | 24 mmol/L | HDL | 42 mg/dL |
| BUN | 38 mg/dL | Triglycerides | 23 mg/dL |
| SCr | 1.05 mg/dL | Total cholesterol | 159 mg/dL |
| GFR | 85 mL/min | Ca | 9.8 mg/dL |
| Glu | 87 mg/dL | Microalb/creat ratio | 18 mg/g |
| HgbA1c | 9% |
Medications:
- Aspirin 81 mg once daily
- Carbamazepine 200 mg – one tablet every morning and 1.5 tablets every evening
- Colchicine 0.6 mg once daily
- Folic acid 1 mg once daily
- Humalog 100 units/mL – 5 units subcutaneously before breakfast and 10 units before dinner
- Hydrochlorothiazide 25 mg once daily
- Lantus 100 units/mL – 44 units subcutaneously once daily before bedtime
- Levetiracetam 750 mg twice daily
- Metformin 500 mg – two tablets twice daily
- Metoprolol succinate ER 50 mg twice daily
- Rosuvastatin 20 mg once daily
- Tamsulosin 0.4 mg once daily
- Thiamine 100 mg once daily
SDH: TM currently has Medicare for insurance. He has a limited income and has not worked in many years due to his medical conditions. He currently does not have a car and the only place to buy food in his town is a dollar store. He lives with estranged wife and her adult son, while TM’s four adult children live out of state.
Additional context: The patient reports that his typical diet consists of the following examples. Breakfast includes one big bowl of honey oat cereal (about two cups) with milk, while lunch would be frozen fettuccine alfredo entree or sandwich on white bread (salami and pepper jack cheese). Dinner is generally a steamed dish from a local Chinese takeout store or General Tso’s chicken with broccoli and brown rice. TM reports that he will eat half and save the other half for the next evening. He mentions that his snacks include granola bars and sometimes crackers, and his beverages are primarily water with daily coffee. Regarding his self-monitored blood glucose readings from the past ten days, TM reports the following values (mg/dL):
- Fasting: 156, 179, 155, 160, 152, 157, 170, 160, 154, 155
- Two hours after dinner: 201, 233, 221, 254, 244, 235, 255, 230
Case Questions
- The “S” in the SEARCH mnemonic stands for “Screen”. What questions would you want to ask TM to assess for potential food insecurities and to direct next steps?
- What clinical parameters observed in TM may be influenced by limited food choices?
- As a pharmacist, what are some specific considerations that you need to consider when recommending and monitoring medications for patients like TM with food insecurity?
- What are some healthy eating strategies that TM is currently embracing?
- In general, what nutritional advice should you provide to TM and patients with similar disease states?
- Patients who must shop at dollar stores face limited food choices. Table 1 provides a list of foods commonly available for purchase at dollar stores. What are some specific recommendations and potential food swaps that you can suggest to TM to optimize healthy eating?
Table 1 . Foods commonly available for purchase at dollar stores
| Type of food | Examples |
|---|---|
| Refrigerated foods |
Beef and broccoli Asian noodle bowl
Cheese: mild cheddar, pepper jack Cheese ziti with meat sauce Chicken fajita bowl Cream cheese Lunch meat: bologna, salami Milk: vitamin D, low fat chocolate Margarine |
| Frozen foods |
Entrees: chicken/turkey/beef pot pie; Salisbury steak meal; fettuccine alfredo; penne with white chicken and cream sauce
Fruits: blueberries, mixed berry blend, sliced peaches, strawberries Meat and fish: breaded chicken patties; breaded chicken nuggets; boneless pork riblets, cod, tilapia, salmon fillet, shrimp Vegetables: asparagus spears, broccoli, cauliflower, pepper stir fry Waffles |
| Dried foods |
Bread: white, wheat
Cereal: bran, honey oats, crisped rice Cookies: chocolate chip, vanilla wafers Crackers: graham, saltines, wheat Dried mixed fruits Fruit snacks Granola bars Lentils Macaroni and cheese Nuts and seeds: almonds, cashews, peanuts, pistachios, sunflower kernels Tortillas: corn, flour Oatmeal: quick oats, instant Pasta: elbow macaroni, penne, rotini, spaghetti Rice: brown, white, yellow |
| Canned, jarred, or bottled foods |
Applesauce
Beans: black, kidney, pinto Fruit: mandarin oranges, pears, peaches, pineapple Meat: chicken, salmon, tuna Salad dressings: Italian, ranch, raspberry, balsamic vinaigrette Soups: classic chicken noodle; low sodium chicken noodle; tomato; vegetable; beef Vegetables: beets, green beans, sweet carrots, sweet corn, sweet potatoes, yams, vegetable blend, white potatoes |
- What types of community-based resources should you connect TM to?
- Oftentimes patients face multiple challenges in addition to living in a food desert, such as a non-working refrigerator. Examine your answer to Question 5 and TM’s medication list. What modifications or counseling would you need to provide to TM in the event he did not have a working refrigerator or freezer?
- If at a follow-up appointment it is determined that changes to diet do not help bring his clinical parameters to goal, what would you recommend then?
Author Commentary
A healthy diet is a key component to preventing and managing many chronic disease states. Pharmacists can play an important role in helping patients understand dietary recommendations. However, before rushing to suggest changes to food choices, pharmacists must first understand the role food insecurities may play in their patient’s life and ascertain options patients have available to them. Food insecurity looks different from patient to patient, and may be intermittent. 12 Food deserts, in particular, may be a contributing factor to consider regarding food insecurity. By better understanding each patient’s individual situation, pharmacists can tailor their recommendations to options that will be realistic for the patient to find and purchase. Even small modifications to diet can improve patient outcomes, so a few targeted and manageable changes is a good place to start. 13
Furthermore, pharmacists have an opportunity to serve an important function in clinical-community linkages, connections between health care providers, public health agencies, and community-based organizations. Pharmacists should take the time to familiarize themselves with the resources available within the community they practice in and could even develop a toolkit for staff use containing information regarding assistance programs for specific populations (e.g., elderly, children, families, pregnant women) and the process for referral. 14 Pharmacists can also advocate on behalf of the communities they serve, such as for policies working toward equitable access to food. 2
Patient Approaches and Opportunities
It is important for pharmacists and student pharmacists to learn about what food insecurity is, the prevalence of food insecurity within the communities they live and work in, and the impact it has on patient health outcomes. The repercussions of ignoring a patient’s circumstances can be detrimental. It is prudent to embrace the components of SEARCH: S creening to see if food insecurity is present, E ducating patients who are at risk of coping strategies, A djusting patient’s medications and/or meal plans as necessary based on their food insecurities, R ecognizing the potential intermittent nature of food insecurity and how it may be unique for each individual, C onnecting patients with resources in the community, and H elping ourselves and other healthcare professionals make the very important connection between food insecurity and health outcomes. 1,2 Healthcare providers should familiarize themselves with resources available in the community and utilize other members of the team such as social workers so they can connect patients with the appropriate resources. Following up with patients to ensure connections were made and patients were able to obtain needed resources is essential. 2
Engage in open dialogue with your patients about food insecurity and what it may mean in terms of preventing and managing chronic conditions and choosing medications that are appropriate and safe. Ensure the care and recommendations that are provided are truly patient-centered and utilize shared decision-making strategies . Understand your patient’s coping strategies and discuss realistic ways to embrace healthier strategies. Some examples of how people may cope with food insecurity include prioritizing quantity of food versus quality of food, diluting food and beverages, eating one heavy meal a day, choosing lower-cost fast foods, skipping meals, or overeating during times of food availability. Educate patients about the link between health, medical conditions, medications, and diet to enhance their understanding and perhaps, acceptance of recommendations. As with most recommendations, utilize motivational interviewing techniques and support the patient’s decisions. 2,12
Related chapters of interest:
- More than just diet and exercise: social determinants of health and well-being
- Plant now, harvest later: services for rural underserved patients
- Communicating health information: hidden barriers and practical approaches
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- Sweetening the deal: improving health outcomes for patients with diabetes mellitus
- Experiences of a Caribbean immigrant: going beyond clinical care
External resources:
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Websites:
- American Diabetes Association. https://www.diabetes.org
- Aunt Bertha. www.Findhelp.org
- Food Apartheid. What does food access mean in America? – https://nutritionstudies.org/food-apartheid-what-does-food-access-mean-in-america/
- Food Empowerment Project. https://foodispower.org/access-health/food-deserts/
- Healthy Food Access Portal. https://www.healthyfoodaccess.org/
- Hunger Relief Organizations. https://www.nal.usda.gov/fnic/hunger-relief-organizations
- USDA Food Access Research Atlas. https://www.ers.usda.gov/data-products/food-access-research-atlas/
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Articles and white papers:
- American Hospital Association. Food insecurity and the role of hospitals. http://www.hpoe.org/Reports-HPOE/2017/determinants-health-food-insecurity-role-of-hospitals.pdf
- Ballick R. Prescription for food: What pharmacists should know about nutrition. Pharmacy Today 2020;26(2):18-19.
- Dubowitz T, Zenk SN, Ghosh-Dastidar B, Cohen DA, Beckman R, Hunter G, et al. Healthy food access for urban food desert residents: Examination of the food environment, food purchasing practices, diet and BMI. Public Health Nutr 2015;18(12):2220–30.
- Nagata JM, Ganson KT, Whittle HJ, Chu J, Harris OO, Tsai AC, Weiser SD. Food insufficiency and mental health in the U.S. during the COVID-19 pandemic. Am J Prev Med 2021;S0749-3797(21)00012-X.
- Kirkpatrick M. An introduction to food insecurity for the advanced practice pharmacist. https://ncccp.net/wp-content/uploads/2018/01/Food-Insecurity-CE-article-for-the-website.pdf
- Patil SP, Craven K, Kolasa K. Food insecurity: How you can help your patients Am Fam Physician 2018;98(3):143-145.
- Wright Morton L, Blanchard TC. Starved for access: life in rural America’s food deserts. https://www.iatp.org/sites/default/files/258_2_98043.pdf
References
- United States Department of Agriculture. Definitions of food security. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx . Accessed February 25, 2021.
- Patil SP, Craven K, Kolasa K. Food insecurity: How you can help your patients. Am Fam Physician 2018;98(3):143-5.
- Lang T, Caraher M. Access to healthy foods: Part II. Food poverty and shopping deserts: what are the implications for health promotion policy and practice? Health Educ J 1998;57(3): 202-11.
- Cummins S, Macintyre S. “Food deserts”–evidence and assumption in health policy making. BMJ 2002;325(7361):436-8.
- Ritchie M, Heidkamp CP, Frazier T. Towards a just assessment tool for identifying food deserts using a space-time economic model. Northeastern Geographer 2018;10:46-61.
- US Department of Agriculture, Economic Research Service. Food access research atlas. Updated 2020. https://www.ers.usda.gov/data-products/food-access-research-atlas/ . Accessed February 2, 2021.
- Dutko P, Ploeg MV, and Farrigan T. Characteristics and influential factors of food deserts , ERR-140, US Department of Agriculture, Economic Research Service, August 2012.
- Algert SJ, Agrawal A, Lewis DS. Disparities in access to fresh produce in low-income neighborhoods in Los Angeles. Am J Prev Med 2006;30(5):365-70.
- Michimi A, Wimberly MC. Associations of supermarket accessibility with obesity and fruit and vegetable consumption in the conterminous United States. Int J Health Geogr 2010;9:49-63.
- Lewis LB, Sloane DC, Nascimento LM, et al. African Americans’ access to healthy food options in South Los Angeles restaurants. Am J Public Health 2005; 95(4):668-673.
- Thibodeaux J. The market inscribed landscape: an institutional logic of food deserts. City & Community 2019;18(1):344-68.
- Kirkpatrick M. An introduction to food insecurity for the advanced practice pharmacist. Northern California College of Clinical Pharmacy. 2018. https://ncccp.net/continuing-education/an-introduction-to-food-insecurity-for-the-advanced-practice-pharmacist/ . Accessed February 25, 2021.
- Ballick R. Prescription for food: What pharmacists should know about nutrition. Pharmacy Today 2020;26(2):18-19.
- Agency for Healthcare Research and Quality. Clinical-community linkages. https://www.ahrq.gov/ncepcr/tools/community/index.html . Accessed February 25, 2021.
- Feeding America. Addressing food insecurity in health care settings. https://hungerandhealth.feedingamerica.org/explore-our-work/community-health-care-partnerships/addressing-food-insecurity-in-health-care-settings/ . Accessed February 25, 2021.