When I was a resident, one of my primary care patients was taken to the emergency department with altered mental status. Unlike the medical mysteries I enjoy reading about in journals, his diagnosis was clear after the first test — a finger stick glucose. He was dutifully taking his diabetes medications, but he was also food insecure and eating irregularly. This led to hypoglycemia, the cause of his symptoms.
Even now, 15 years later, that patient’s story has stuck with me. I’m still a primary care doctor, but I’m also a health researcher who focuses on interventions to improve health by addressing food insecurity and other health-related social needs. Even though I’m amazed every day by biomedicine’s scientific advances, I’m frustrated that something as basic as access to nutritious food is out of reach for so many.
In this context, the U.S. Preventive Services Task Force (USPSTF) is reviewing the evidence on screening for food insecurity in primary care. Recently released for public comment, their draft statement reveals that, after a careful and thorough review, the USPSTF plans to issue an “I” recommendation, meaning that “the current evidence is insufficient to assess the balance of benefits and harms of screening for food insecurity on health outcomes in the primary care setting.”
Many people will be disappointed by this. Given that the harms of food insecurity are so clear and the solutions — food or money for food — so obvious, how could this be?
It is important to note that this kind of recommendation is by no means unique to food insecurity, and USPSTF’s judgement is far more complicated than just determining whether something is a threat to health. Many devastating conditions, such as ovarian and pancreatic cancer, do not have a screening recommendation.
For screening to improve health, a great many pieces have to come together. Not only does the condition have to be harmful, but screening has to detect more cases than would otherwise come to light (or detect them at an earlier, more treatable stage), and we have to be able to offer effective treatments that people would not otherwise receive.
Given all this, I have to say that I agree with the USPSTF that the evidence needed to recommend screening for food insecurity in primary care just isn’t there right now. In this case, it’s not that we don’t know food insecurity is harmful (it is) or how to identify it (a simple 2-item screener works very well), it’s whether specific healthcare-involved interventions can make a difference in health outcomes. That is where the evidence is insufficient.
So where does this leave us?
First, we need more, and better, research (you probably expected a researcher to say this). The good news is that we are getting it. The NIH has issued a notice of special interest for food insecurity research; the American Heart Association has launched a Food is Medicine initiative called Health Care by Food; and Tufts University started a Food Is Medicine Institute, just to name a few recent developments. Five years from now, we will be in a very different research landscape.
Second, even if it is not clear that we should be screening for food insecurity right now, there are still things we in healthcare can do when food insecurity comes to light. In particular, we can contextualize our care by learning from individuals how food insecurity is affecting their health, and adapting care plans to be better attuned to their situation. For example, for people with diabetes who experience food insecurity, we can choose medications that minimize hypoglycemia risk.
Third, while we may need more evidence for the narrow question of food insecurity screening in the primary care setting, we don’t need more evidence for the broader question of whether we as a society should take action to reduce food insecurity. Food insecurity is an injustice no one should face, and we know that public policy can alleviate it.
The U.S. has high rates of food insecurity compared with many other countries, and the reason for this comes down to a few key policy areas: child benefits, pensions for older adults, income support for people with work-limiting disabilities, and unemployment insurance. In each area, the U.S. stands out as offering substantially less robust policies than our peers.
And at times when the U.S. had stronger policies for people in these situations — such as when the 2021 Expanded Child Tax Credit or pandemic-related expansions of unemployment insurance were in effect — there was substantially less food insecurity. Indeed, the likely explanation for the major rise in food insecurity in 2022 is the expiration of these policies.
So putting all of this together, while I’m disappointed that the state of the evidence for food insecurity screening in primary care isn’t stronger right now, I’m very optimistic about the evidence pipeline, and I know there are things we can do to help those experiencing food insecurity in the meantime. Perhaps most importantly, we should view this draft report as an opportunity to recognize that addressing food insecurity outside of healthcare may be even more important than inside it.
Creating a system of public policies that ensures the conditions everyone needs to be healthy is the real path to better population health. Indeed, if all we do is try to mitigate — from inside the healthcare system — the health effects of food insecurity once it occurs, we will have missed our best opportunity for a healthier country.
Seth A. Berkowitz, MD, MPH, is an associate professor in the Division of General Medicine and Clinical Epidemiology at University of North Carolina at Chapel Hill, and author of the recent book, Equal Care: Health Equity, Social Democracy, and the Egalitarian State.
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