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Special Report

Food Insecurity Can Lead Straight to the ED

Shaw, Gina

doi: 10.1097/01.EEM.0000743172.20234.d1
    food insecurity, poor health

    Before COVID-19 hit the United States, food insecurity was at its lowest point since the Great Recession of 2007-2008. That may sound like a good thing, but it still meant that 37 million people in the United States were food insecure in 2018.

    Then came the pandemic. Feeding America, the nation's largest hunger relief organization, estimated that more than 50 million people, including 17 million children, were food insecure in October 2020. And the organization projected that as many as 17.1 million more people could become food insecure if the pandemic pushed unemployment and poverty to Great Recession levels. (Feeding America National Report. April 20, 2020;

    “We think that food insecurity rates have probably doubled since pre-pandemic times,” said Hilary Seligman, MD, a professor of medicine and of epidemiology and biostatistics at the University of California, San Francisco. “We had anticipated that it might go up even more, but the increase in SNAP [Supplemental Nutrition Assistance Program] benefits and direct financial payments to households via the COVID relief packages seems to have been quite effective. Food is one of the things that disappears out of a household budget first, so when you replenish it with cash, food is one of the first things purchased.”

    Food was the single most common item on which households spent stimulus payments, with 80 percent of survey respondents who spent their stimulus checks saying they used at least some of their payments on food, according to the Census Bureau.

    Most emergency physicians probably won't be surprised to learn that new research from investigators at Columbia University Irving Medical Center in New York City found that Black, Asian, and Latino people, those with an annual income less than $100,000, and those living with children were significantly more likely to face new food insecurity. (Public Health Nutr. 2021 Jan 27;1.)

    There appear to be disparities in the underlying reasons for food insecurity during the COVID-19 pandemic. Demographers at the University of Texas at El Paso found that among food-insecure households, Black households were more likely to report that they could not afford to buy more food; Asian and Latino households were more likely to be afraid to go out to buy food; Asian households were more likely to face transportation issues when purchasing food; and white households were more likely to report that stores did not have the food they wanted. (J Racial Ethn Health Disparities. 2020 Oct 14:1;

    All of this particularly affects children, said the study's lead author, Danielle Xiaodan Morales, PhD, a postdoctoral fellow in sociology at the University of Texas at El Paso. “Many households with children are suffering from food insecurity, and many of those we interviewed specifically reported that the children in their homes did not have enough to eat. That shows how severe the situation is: Even in food-insecure households, parents typically make efforts to ensure that their children have enough to eat even when they themselves do not. Now things have become so bad that they are not even able to make sure that their kids have food all the time.”

    Dr. Morales said school was a protective factor for food security before the pandemic because children received meal help from school. “While schools are still running food support programs even as learning is virtual, it can be much more difficult to access the food in these circumstances, so the protective effect of school against food insecurity has disappeared,” she said.

    Poorer Health

    Food insecurity translates directly into poorer health—and more visits to the emergency department. A U.S. Department of Agriculture report found that food insecurity was linked to 10 of the costliest and deadliest preventable diseases in the country, including diabetes, hypertension, asthma, heart disease, kidney disease, and stroke. (July 2017; Research published in 2018 found that food insecurity is also associated with significantly higher rates of emergency department visits as well as inpatient admissions. (Am J Manag Care. 2018;24[9]:399;

    “Some of this may be reverse causation, i.e., when you are sick you are less able to work and may have higher medical expenses, thus could be more likely to be food insecure,” said the study's lead author, Seth Berkowitz, MD, MPH, an assistant professor of general medicine and clinical epidemiology at the University of North Carolina School of Medicine. “But a growing body of literature shows an association between food insecurity and subsequent poor health, suggesting that reverse causation is not the only explanation.”

    The emergency department is a powerful window into food insecurity because lacking food can worsen chronic health conditions, Dr. Berkowitz said. “That can lead to exacerbations that necessitate an ED visit,” he explained. “I think the other reason is that EDs offer care for everyone, even when they can't access care anywhere else. Thus, for people who have lost their health insurance or can't access outpatient care for other financial reasons, they may seek care in the ED.”

    Food insecurity and poor health contribute to each other in an endless vicious cycle to some extent. “The more food insecure you are, the more chronic conditions you tend to have. And poor health in the United States is expensive. We know that food-insecure households have more than $1800 of excess health care expenditures annually,” Dr. Seligman said, referring to Dr. Berkowitz's study in Health Services Research. (2018;53[3]:1600;

    A person in poor health is much more likely to become food insecure, she said. And those who are food insecure are also less likely than others to be fully employed, which means they are less likely to be fully insured, which in turn means they are more likely to postpone outpatient primary care visits, resulting down the line in more ED visits. “We call it the cycle of food insecurity and chronic disease,” Dr. Seligman said. “It's a cycle that's hard to get out of.”

    It's unclear whether increasing food insecurity as a result of the pandemic has directly driven an increase in related ED visits, Dr. Seligman said. “While the pressure of poor health that comes from food insecurity contributes to ED visits, there are other pressures, such as the fear of exposure to the virus and the recognition that EDs are swamped with patients, that might push people not to go to the emergency department.”

    Hunger Vital Signs

    What is clear, however, is that many of the people who do come to the emergency department for care will come from food-insecure households, whether they directly tell their care team about this situation or not. Emergency physicians can make an enormous difference in the lives of these people and their families by helping them connect with available resources.

    To determine if a patient comes from a food-insecure household, start with a simple two-item questionnaire validated by Dr. Seligman and colleagues using this text:

    “Now I'm going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for (you/your household) in the last 12 months—that is, since last (name of current month).

    “The first statement is, ‘We worried whether (my/our) food would run out before (I/we) got money to buy more.’ Was that often true, sometimes true, or never true for (you/your household) in the last 12 months?

    “‘The food that (I/we) bought just didn't last and (I/we) didn't have money to get more.’ Was that often true, sometimes true, or never true for (you/your household) in the last 12 months?” (Public Health Nutr. 2017;20[8]:1367;

    A response of “sometimes” or “often” true to either question is consistent with food insecurity. These two questions, Dr. Seligman and her group found, have sensitivity across high-risk population subgroups of 97% or more and a specificity of 74% or more for food insecurity.

    “We call these the hunger vital signs,” Dr. Seligman said. “There's a lot of stigma attached to hunger and being food insecure, so I preface these questions by telling people that I ask all of my patients about access to food because it is a very important element of health, and that there are many community resources available for those who need them.”

    That's a critical piece of the conversation, she said. “Clinicians need to communicate to patients the importance of access to food for their health. For example, I remind people that if someone is having complications from diabetes, access to good food is just as important as access to medications for keeping their disease under control. Patients need to know that you're asking these questions because you want to make sure they have access to food, not to stigmatize them or put them at risk. Parents may have fear that their children will be taken out of their home because of neglect if they reveal that there isn't adequate food in the house.”

    For patients whose responses to the hunger vital sign questions reveal food insecurity, emergency physicians or the emergency department social worker can employ various resources.

    • Connect the patient to federal nutrition programs. “SNAP makes a big difference,” Dr. Seligman said. “It has been found to reduce food insecurity by 20-30 percent, which is a lot. All clinicians should have a general idea of the SNAP eligibility criteria in their area. But that isn't necessarily enough. Many patients who are eligible for SNAP may not want to sign up, and many who do sign up remain food insecure.” (USDA. April 2010;
    • Help eligible patients—women who are pregnant or postpartum and infants and children up to age 5 who are at nutritional risk—sign up for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). (
    • Maintain a list of community-based options that are part of the charitable food system, such as food banks and food programs affiliated with Feeding America, as well as other resources like congregate meal programs for older adults (unfortunately, many are temporarily closed due to the pandemic) and information about how to access school lunch program resources when a child is not physically in school.
    • Some state Medicaid programs offer home-delivered medically tailored meals for vulnerable patients. A study led by Dr. Berkowitz found that participants in these programs have fewer emergency department visits and inpatient admissions. (Health Aff. 2018;37[4]:535;
    • Feeding America offers a toolkit for physicians and health care organizations to help treat food insecurity in their patients. (

    Beyond direct work to identify food-insecure patients and connect them with resources, emergency physicians can serve as important community advocates for SNAP benefits and other nutrition programs. “We need physicians to remind legislators, policymakers, and their friends on social media that SNAP is vitally important to people's health, and that when we support people in becoming more food secure, they are healthier,” Dr. Seligman said.

    “By spending money on SNAP up front, we save more money in annual health care expenditures. Otherwise, we just kick the can down the road. When a large segment of the population is food insecure, the consequences will be borne eventually by the health care system. We can either invest in more very expensive health care or upstream in food security in a way that is much cheaper and prevents a lot of pain for the individuals who have to suffer with food insecurity.”

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    Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work

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