Original Research

Food Insecurity Among Veterans: Resources to Screen and Intervene

A screener was created in the VA electronic health record clinical reminder system to facilitate an interdisciplinary approach to identifying and addressing food insecurity.

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References

Nearly 1 in 8 households—and 1 in 6 households with children—experienced food insecurity in 2017, defined as limited or uncertain availability of nutritionally adequate and safe foods.1 Food insecurity is often even more pronounced among households with individuals with acute or chronic medical conditions.2-6 Moreover, food insecurity is independently associated with a range of adverse health outcomes, including poorer control of diabetes mellitus, hypertension, depression and other major psychiatric disorders, HIV, and chronic lung and kidney disease, as well as poorer overall health status.7-14 Food insecurity also has been associated with increased health care costs and acute care utilization as well as increased probability of delayed or missed care.15-19

The relationship between food insecurity and poor health outcomes is a complex and often cyclic phenomenon (Figure 1). Poor nutritional status is fueled by limited access to healthful foods as well as increased reliance on calorie-dense and nutrient-poor “junk” foods, which are less expensive and often more readily available in low-income neighborhoods.5,20-24 These compensatory dietary patterns place individuals at higher risk for developing cardiometabolic conditions and for poor control of these conditions.5,8,9,12,25,26 Additionally, the physiological and psychological stressors of food insecurity may precipitate depression and anxiety or worsen existing mental health conditions, resulting in feelings of overwhelm and decreased self-management capacity.5,8,27-31 Food insecurity has further been associated with poor sleep, declines in cognitive function, and increased falls, particularly among the frail and elderly.32-34

Individuals experiencing food insecurity often report having to make trade-offs between food and other necessities, such as paying rent or utilities. Additional strategies to stretch limited resources include cost-related underuse of medication and delays in needed medical care.4,17,31,35 In a nationally representative survey among adults with at least 1 chronic medical condition, 1 in 3 reported having to choose between food and medicine; 11% were unable to afford either.3 Furthermore, the inability to reliably adhere to medication regimens that need to be taken with food can result in potentially life-threatening hypoglycemia (as can lack of food regardless of medication use).5,26,36 In addition to the more obvious risks of glucose-lowering medications, such as insulin and long-acting sulfonylureas in patients experiencing food insecurity, many drugs commonly used among nondiabetic adults such as ACE-inhibitors, β blockers, quinolones, and salicylates can also precipitate hypoglycemia, and food insecurity has been associated with experiences of hypoglycemia even among individuals without diabetes mellitus.32,37 In one study the risk for hospital admissions for hypoglycemia among low-income populations increased by 27% at the end of the month when food budgets were more likely to be exhausted.38 Worsening health status and increased emergency department visits and hospitalizations may then result in lost wages and mounting medical bills, contributing to further financial strain and worsening food insecurity.

Prevalence and Importance of Food Insecurity Among US Veterans

Nearly 1.5 million veterans in the US are living below the federal poverty level (FPL).39 An additional 2.4 million veterans are living paycheck to paycheck at < 200% of the FPL.40 Veterans living in poverty are at even higher risk than nonveterans for food insecurity, homelessness, and other material hardship.41

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