'Do you have food in the house right now?' How doctors can identify and combat effects of food insecurity

A physician involved in a successful fresh food prescription program in Guelph, Ont. says doctors should actively screen for food insecurity. “We’re trained to inquire about the Canada food guide and whether patients are getting their fruits and vegetables, but what we’re not trained to do is ask about whether a patient is able to access the foods we’re advocating for,” said Dr. Melanie Bluhm, a family physician with the Guelph Community Health Centre. “If physicians don’t do this, then they run the risk of making a value judgement about a client or about a parent that may not be true,” she said in a conversation with the Medical Post. “It also adds to the burden and the stress of parents who are already living with income insecurity." Fresh food prescription program Asking about access to food means physicians can work with patients to help them through programs. “They need to be able to provide patients with culturally relevant and dignified, de-stigmatized community support that can alleviate that food insecurity,” Dr. Bluhm said. One pilot program is a fresh food prescription program run out of the Guelph Community Health Centre. Through it, 60 food insecure patients who had one or more cardio-metabolic condition were given coupons to a local market for 12 weeks. The coupons were for community markets operated by the SEED, a food security program the health centre also runs. The markets are open five-days-a-week in different locations. Everyone can shop at the SEED markets—Dr. Bluhm has shopped there too, discovering new vegetables. Food is sold on a sliding scale, available at-cost for some clients. The coupons look like gift cards with no expiration date, reducing any stigma of using them. During follow-up, participants reported eating fruits and vegetables more often than before the study by an average of one serving a day. The findings were published in Archives of Public Health in 2021. Read: Manitoba strikes deal with drugstore chain to supply free menstrual products People know they have to eat healthy food, but Dr. Bluhm said, affordable foods tend to be low-value from a nutritional perspective. “This program has allowed people to get the food they know they need to eat.” It also allows families to try new foods without taking on the risk of a given family member not wanting to eat it, Dr. Bluhm noted. “Food waste is not an option for them.” Children have been proudly reporting to Dr. Bluhm that they’ve been trying more fruits and vegetables thanks to the program. The fresh food prescription program is now serving another 61 households, with close to 200 people benefiting from the intervention. With the pandemic, the SEED became an online store that delivers orders straight to clients’ doors. Participants in the fresh food prescription program get $10 per week per person in the household, so a family of five would get $50 a week, uploaded to their online SEED account. “We’re nearing the end of one year intervention,” explained Abby Richter, a dietitian at Guelph Community Health Centre and lead in the fresh food prescription program. Richter and her team check in with participants to make sure everything is working, and process orders for those who don’t have access to a computer. The food delivery service works well for the SEED clients because it “removes a lot of barriers to getting to a location,” Richter said. Inflation is also hitting the SEED, so prices have had to rise. Participants in the fresh food prescription program are getting less food for their $10 than they were a year ago, Richter said. The program is working on the right amount to give to each household. Some participants find the current amount adequate, others think it's too much and others not enough. “The goal of the intervention was never to fully compensate people for all their fruits and vegetable needs, but we are definitely looking at the dollar amount we’re giving because of inflation and the changing costs of groceries,” Richter said. Read: Social prescriptions: Why some healthcare practitioners are prescribing food to their patients How to ask about food insecurity In order to screen effectively for food insecurity, physicians should ask all their patients about it. “I think by asking the question generally to everybody, we reduce that stigma,” Dr. Bluhm said. Normalizing the challenge of getting affordable food may help. For example, Dr. Bluhm said physicians could ask: “Prices have gone up consistently lately and it is making it really hard for people to access the food that they would like. Do you ever experience this or have you experienced this lately?” Asking about other barriers to accessing food is also a good idea. For example, “Do you ever have difficulty getting the food you need—either because you can’t get out to get the groceries or because financially it is challenging for you?” Physicians can then direct patients to helpful programs. “It is important for physicians to be aware of programs available in their community,” Dr. Bluhm said, adding that the pilot project helped her discover programs in her own community. Programs that may alleviate food security could include: Community gardens Neighbourhood programs Food share programs School-based programs The programs might not provide fresh fruit and vegetables, but if they provide regular staples, “it frees up more of their income to use for fresh fruits and vegetables,” she said. State of food insecurity in Canada A recent report found that 15.9% of households in Canada’s provinces experienced some level of food insecurity between 2020 and 2021. This translates into 5.8 million people, including 1.4 million children. Quebec had the lowest rate at 13.1% while Alberta had the highest at 20.3%. A third of Indigenous peoples living off-reserve experienced food insecurity. The data, from Statistics Canada’s Canadian Income Survey, does not include people living on-reserve. Numbers from the territories are not yet available. The report suggests that levels of food insecurity have remained stable over the past three years, but Valerie Tarasuk, lead author of the study and professor of nutritional sciences at University of Toronto, said that the problem could get worse. “The situation now is that inflation and prices are skyrocketing,” Tarasuk said in an August press release. “People with severe food insecurity will suffer more deprivation, and more often turn to acts of desperation in the face of hunger. That’s the urgent challenge for policymakers.” Read: Nutrition in adolescence: Multiple challenges, lifelong consequences and the foundation for adult health Tarasuk leads PROOF, a research program at the University of Toronto that studies food insecurity and interventions to address it. The report is published on PROOF’s website. What long-term solutions are needed Research by PROOF centres on the idea that food insecurity is a problem of inadequate and insecure income. For screening to be appropriate and effective, it needs to lead to actions that improve households’ financial circumstances. In July, Alberta Health Services published recommendations for identifying food insecurity in healthcare settings. The main recommendation was to screen everyone for poverty, as well as—or instead of—food insecurity, with the question suggested by the Centre for Effective Practice: “Do you ever have difficulty making ends meet at the end of the month?” In a Globe and Mail article about Toronto’s program, Tarasuk criticized food prescription programs, saying they don’t go far enough to help with food insecurity. “It’s reducing their struggle to a box of produce,” she told the Globe and Mail. “The response to the problem is miles apart.” Fresh food prescription programs may not solve the root causes of food insecurity, but they do provide immediate access to healthier food. The feedback from the participants in Guelph’s fresh food prescription program were overwhelmingly positive about the increased access to fresh fruits and vegetables. One participant commented in the Archives of Public Health paper that participation in the program “meant that for those past several months, I didn’t have a diet based on carbohydrates, I could eat a diet that could have a lot more fruits and vegetables and proteins, which is so good for me when I’m [ …] trying to get some diabetes under control.” Physicians can also take action to promote change. “In a broader perspective, physicians also need to advocate for long-term policies that help alleviate poverty and support low-income populations,” Dr. Bluhm said. Some provinces are addressing the rising costs of food. In June, New Brunswick Medical Society announced their support for the provincial government’s new Emergency Fuel and Food Benefit. “With the cost of living rising so steeply, it has become more challenging to afford housing, quality nutrition and favourable overall living conditions. Physicians support a focused and coordinated approach to reducing poverty in the province and this initiative is a positive step in that direction,” Dr. Mark MacMillan, president of the New Brunswick Medical Society said in a press release. Dr. Bluhm said she hopes more fresh food prescription programs become available. A systematic review by Richter and colleagues suggests the programs increase fruit and vegetable consumption, although their direct impact on health remains unclear due to varying study designs. The review was published in a 2021 issue of the American Journal of Health Promotion. Fresh food prescription programs can provide immediate access to healthy food while healthcare professionals and others advocate for poverty reduction. Read: The evolving role of therapeutic nutrition

'Do you have food in the house right now?' How doctors can identify and combat effects of food insecurity

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