The 38-year-old man entered the hospital with a big toe oozing pus and a blood sugar that was three times the normal level. After treating a bone infection and amputating his toe, his doctors and nurses taught him how to manage his diabetes, including what foods to eat. The man told them that the infection was a wake-up call and vowed to follow a diabetic diet and take his medicine.
Two years later, he appeared in my clinic, clutching a bottle of red Gatorade. He had been sleeping on his brother’s couch and was only taking two of the five medications he had been prescribed. He told me not to bother renewing the other three, since he couldn’t afford the $20 co-pay for them at the charity pharmacy. The other two he could get at a local pharmacy that offered them for free, as part of a promotion to attract customers. For food, he ate whatever he could get, mostly at local soup kitchens. He said he wanted to eat the right foods and take all of his prescribed medicines, but he couldn’t find work and had no money. Seeking help from relatives wasn’t an option.
“They got money problems of their own,” he said.
According to an article this month in the American Journal of Medicine, my patient’s predicament is common: nearly one in three U.S. adults with a chronic disease has problems paying for food, medicine, or both. Researchers at Harvard and the University of California at San Francisco studied data from the 2011 U.S. Centers for Disease Control’s National Health Interview Survey.
Of the 10,000 adults who reported that they had a chronic disease such as diabetes, asthma, arthritis, high blood pressure, stroke, a mental health problem, or chronic obstructive pulmonary disease, nearly one in five said they said they had problems affording food during the past 30 days, a condition called “food insecurity.” Nearly one in four said they had skipped medication dosages because of cost. More than one in ten said they had problems paying for both food and medication.
“The strength of the association was surprising,” said Dr. Seth Berkowitz, an internist and the study’s lead author. “How are we supposed to manage these complex diseases when a third of our patients can’t afford food, medication, or both?”
The 2011 National Health Interview Survey was the first to include questions asking about ability to pay for food. But the health effects of food insecurity are well-documented. Numerous research studies have found that children who live in families with problems affording food are at significant risk of anemia, depression, learning and behavioral problems, and are more likely to be overweight. Among adults, difficulty affording food is associated with obesity, high blood pressure, and diabetes—conditions that are highly influenced by diet. HIV-positive patients with food insecurity are more likely to have uncontrolled disease and to die of AIDS than those without problems affording food. Diabetic adults with problems paying for food are more likely than other diabetics to have erratic blood sugars and to visit the emergency room more often because of low blood sugar. Nutrition researchers explain that difficulty affording food doesn’t result in lower calorie consumption, since processed, higher-calorie foods are typically cheaper than nutrient-rich, perishable foods such as vegetables, fruit, fish, and low fat milk products.
“It’s not that there isn’t any food available, it’s that there isn’t appropriate food,” said Rose Anderson, a nurse practitioner who works with Camillus Health Concern, a Miami-based group that serves low income, predominantly homeless patients. “It’s difficult for the diabetics.”
Anderson spoke with me outside a soup kitchen, where she was examining and treating people who had just eaten a meal of white rice, chicken stew, pale iceberg lettuce, and chocolate cupcakes. In the parking lot, volunteers unloaded a car full of day-old pastries and bread from a local supermarket.
“They only serve food once a day, and fresh vegetables are in short supply,” she said.
Her patient Ed Franco, 51, a legally blind diabetic man who has slept on friends’ sofas, in a van and on the streets of Miami since losing his job in air conditioning sales five years ago, said he spends most of his days trying to find food. He frequently goes to one of a handful of churches that offer free meals that he said mostly consist of starchy foods such as pasta and bread, as well as some meat. Some days, he visits a local food court where restaurants offer free samples. On Wednesdays and Sundays, he goes to a local McDonald’s that sells burgers for 49 cents.
“I call it poison,” he said. “But you can’t really choose what you eat.”
Franco said he gets $189 a month in food stamps, but he lacks a regular place to keep perishable food, and “the sugar-free stuff is very expensive.” Anderson said that his lack of a refrigerator also limits the options for treating his diabetes; insulin has to be kept cold, so she only prescribes him medication that comes in pill form.
The American Journal of Medicine analysis reported that chronically ill adults who reported “food insecurity” were much more likely to skip medication due to worries about cost than were those who denied problems affording food. But the article’s findings suggest that two programs, Medicaid and the federally-funded Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program, might help. Medicaid usually covers basic medications with a small or no co-pay. WIC pays for specific foods for low-income pregnant women, mothers of small infants or those who breastfeed, and children younger than five. Compared with others of similar income, adults who were enrolled in one of these two programs were less likely to say they had problems obtaining healthy foods or prescribed medicine due to cost.
The researchers didn’t find a similar link among adults who said they got food stamps through the federal Supplemental Nutrition Assistance Program (SNAP), though other studies have found that children whose families got food stamps are much less likely to be “food insecure” than kids in families of similar income. Berkowitz said that this could be because the adults who actually enroll in the food stamp program tend to live in deeper poverty and have more health problems than other adults who qualify but don’t enroll, while the use of WIC is more widespread among families who qualify.
“WIC has traditionally been very good at enrolling everyone who qualifies,” he said. “It was meant as a health program, to avoid complications of malnutrition in children. SNAP was not meant as a health benefit, and the whole ethos is different. It still has lots of stigma, and the people in it tend to be much worse off.”