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.”
Learning about food insecurity isn’t part of the usual training for doctors who focus on adults, and I have never worked in a clinic that routinely asked patients if they had problems affording food and helped them apply for food assistance. In contrast, my colleagues in pediatrics and obstetrics routinely refer their patients to WIC, and are very familiar with the program. The American Academy of Pediatrics has even issued a position statement urging its members to collaborate with local WIC programs and provide information about WIC to patients who might be eligible. Some of this familiarity stems from the program’s rules: In order to qualify, women have to meet with a health professional such as a doctor, nurse practitioner, or dietician who determines whether they or their baby are at risk of having a nutritional deficiency. WIC is often administered by health departments, and frequently has offices in hospitals and clinics. In addition to providing food vouchers, WIC offers nutrition education, helps mothers who are trying to breast feed, and refers mothers and children to social service programs.
The SNAP program, for the most part, operates independently of the health system. Applicants aren’t required to meet with a health professional, and most internists and other adult medical specialists don’t routinely make direct referrals to the program.
But what if SNAP were more like WIC, and referrals to the program became second nature for clinics serving chronically ill, low-income people? I don’t want to add to the lengthy laundry list of problems for which primary care physicians are expected to screen. But some aspects of the WIC program, such as its close collaboration with health departments, hospitals and clinics, as well as its heavy focus on education, might provide a model for how the SNAP program could work with health professionals.
“We should get smarter about how to address these things at a clinic or health system level,” Berkowitz said.
One idea might be for clinic check-in staff to screen patients for food insecurity when they arrive for their appointment, perhaps by having them answer some questions on a tablet or mobile phone that would automatically trigger a referral to SNAP. It doesn’t have to be complicated—one study found that a single question—“In the past month, was there any day when you or anyone in your family went hungry because you did not have enough money for food?”—was effective at determining food insecurity among parents at a clinic serving low-income children.
Another idea might be to provide some healthy foods to patients directly at the doctors’ office. A Spanish study published in The New England Journal of Medicine last year randomized more than 7,000 patients who were at high risk of heart disease to a “Mediterranean diet,” which included free supplies of extra-virgin olive oil or a mix of walnuts, almonds, and hazelnuts, or to counseling on a low fat diet that recommended fruits, vegetables, fish, low-fat dairy and bread, potatoes, pasta or rice.
At the end of five years, the people in the Mediterranean diet groups were significantly less likely to have had a stroke than those in the low fat diet “control” group. (There was no significant difference in heart attacks or in the overall death rate, however.)
Some doctors have adopted the strategy of providing healthy food “prescriptions” to low-income children and their families. In 2010, pediatrician Shikha Anand collaborated with Wholesome Wave, a nonprofit, to establish the Fruit and Vegetable Prescription Program, which enables teams of doctors, nurses and nutrition educators to prescribe vouchers that can be redeemed for free produce at local farmers’ markets. Early data suggests the program is effective in increasing fruit and vegetable consumption and in reducing body mass index, a measure of weight, among overweight and obese children.
"There's a growing body of evidence that this program affects food security," Dr. Anand said. "It's not just the effect of getting the prescription, it's the effect of engaging in that conversation about the connection between food and health with that primary care team that you know and trust."
The Fruit and Vegetable Prescription Program’s scope is limited—thus far it has enrolled just over 1,100 obese or overweight children in six states and the District of Columbia.
And even though the 2014 federal Farm Act tries to increase food stamp recipients’ access to fruits and vegetables, budget cuts and increased demand make it unlikely that food insecurity, and its attendant health problems, are unlikely to diminish anytime soon. Nor are those of us who live in states that refused to participate in the Medicaid expansion likely to see much of an improvement in our patients’ ability to pay for their medication—a recent analysis estimated that more than 32 million people nationally will remain uninsured after the Affordable Care Act is fully implemented. If we’re going to succeed at treating our patients, it’s crucial we know about their financial problems—and figure out ways to help them manage their illnesses under difficult circumstances.