The DEI Shift
The DEI Shift
Food Insecurity- Part 1
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Learning Objectives:
- Define food insecurity and how it differs from hunger.
- State the prevalence of food insecurity in the US.
- Summarize some of the physical and psychological impacts of food insecurity.
- Describe how public school lunch programs can combat food insecurity.
Co-hosts/Producers: Dr. DJ Gaines, Dr. Ricardo Correa
Executive Producer: Dr. Tammy Lin
Co-Executive Producers: Dr. Pooja Jaeel, Dr. Tiffany Leung
Senior Producers: Dr. Maggie Kozman, Dr. DJ Gaines
Editor/Assistant Producer: Emily Han and Deepti Yechuri
Production Assistants: Clara Baek, Lynn Nguyen
Website/Art Design: Ann Truong
Music: Chris Dingman
Continuing Medical Education/Maintenance of Certification (CME/MOC) credits are available as an American College of Physicians national member benefit. To submit for CME/MOC credit for this episode, visit: https://www.acponline.org/cme-moc/online-learning-center/food-insecurity-part-1
Connect with us on Instagram at @thedayshift.pod and via email at thedayshifthealthcare@gmail.com
[00:00] Gaines (DG): Welcome everyone! We are so excited to share this episode with you. It was chock-full of so much information that we had to split it into a two-episode series. In Part 1, we introduce our wonderful guest Dr. Suja Mathew and review some of the basics of food insecurity, including some of its psychological and physical impacts. In Part 2, we expand from there, discussing some of the political factors that perpetuate food insecurity and what we can do to combat this issue.
DG: Thanks for joining everyone. Now, on to the show!
[00:29] DG: Welcome to “The DEI Shift”, a podcast focusing on shifting the way we think and talk about diversity, equity, and inclusion in the medical field. I'm DJ Gaines, a current chief medical resident at the UCSD internal medicine program and future academic hospitalist at the VA San Diego…
Correa (RC): …and I am Ricardo Correa, a fellowship director for Endocrinology, Diabetes, and Metabolism, and the director for diversity and graduate medical education for the University of Arizona College of Medicine Phoenix, and we will be your co-hosts for this episode. Food insecurities affect mainly our underserved, underrepresented population. It is one of the components of social determinants of health that contribute to many chronic conditions of our patients. In all seriousness, this is an important topic that can have a huge impact on our patients’ wellbeing and our patients’ psychological health.
So, let's dive right into it!
DG: So tonight, we want to welcome our guest who will be teaching us about this topic, Dr. Suja Mathew. Dr. Mathew is an internal medicine physician at Cook County Health and Hospitals System, where she also serves as a Chair of Medicine. She previously served as the Program Director for the Cook County internal medicine residency program. She received her bachelor's degree in Public Policy from the University of Chicago and a medical degree at the Pritzker School of Medicine. She remained at University of Chicago to complete her residency in internal medicine. She is immediate past governor of the Illinois Northern chapter of ACP and currently served on ACP’s Board of Regents, along with a number of other national ACP committees.
She has a strong interest in addressing food insecurities and is one of the co-chairs of Doctors or a Hunger Free America, DHFA, which engages physicians and activities that advance public policies and programs aimed at eradicating domestic hunger. Welcome to the program, Dr. Mathew!
Mathew (SM): Oh, it’s such a—
DG: —may we call you Suja?
SM: Oh yes, definitely—call me Suja! It's such a pleasure to be here with you, thank you!
[02:46] RC: Before we dive in, we’d love to get to know you a little bit better. So it is time for our “A Step in Their Shoes” segment, where our guest shares an element of their background or culture that has been important in their life, and we, as listeners, flex our muscles in the realms of cultural competence and humility.
DG: So Dr. Mathew, is there a factor or something you'd like to share with the audience today?
SM: Yeah, thank you, that's such an interesting option for me this evening. I think that so important in my life has been that my culture is so focused on intergenerational relationships and cross-generational living. And as an example, my own household, there are three generations in my household. We've had, at times, both my parent and my husband's parent in our house at the same time, children, grandchildren, our aunts and uncles are very close, and cousins—second, third, fourth cousins are all cousins and like brothers and sisters—so I think what's been such an important part of my culture is how close and related our families are. And it definitely impacts decisions that we make. It's a focus away from sole independence to one of caring for our community.
RC: I feel so identified with you. In my culture, it’s the same, so the more the merrier. So having a lot of people at home and sharing all of our experiences with them—I think, make us different and make us sometimes take better decisions or be more mature. So thank you for sharing that, Suja.
SM: It's sometimes a sense of duty too, isn’t it, Ricardo? I certainly feel a strong sense of duty towards my family members. My mother has been living with me since 1997 when my father passed. And I was only in my mid-twenties at that time. That's a lot of duty, a lot of responsibility, but again, caring for one another, it's just such a closely intertwined relationship in our communities.
RC: Totally agree.
SM: Yeah.
DG: Thanks for sharing, Suja. Wow...I definitely have heard some patients share, I would say disappointment, in the way that American culture is so focused on independence. And that you lose that family aspect in America, in some cultures, in some parts of America. That’s exactly it, that’s very interesting.
SM: Yeah.
[05:40] DG: Alright, so let's get started! So first, I think it is important that we understand the definition of food insecurity. Suja, can you help us define food insecurity?
SM: Yeah, thanks, DJ. So, let's start by just separating out hunger and food insecurity. Those terms are used quite interchangeably. I think most of us, when we use the terms, understand the point that we're trying to make, but strictly speaking, hunger is a physiologic sensation. Right now it's well past nine o'clock, I haven't had dinner yet, and I'm feeling a little hungry—we've all experienced that. Chronic hunger, of course, is far more correlated to food insecurity. And so, food insecurity is a concept as defined by the USDA. And there are different levels of food insecurity, but all of them relate to not having consistent, reliable access to food. There are levels of food insecurity—or rather, I should say, food security. There are levels of food security—and that would be high food security, marginal food security, low food security, and also very low food security. And that—again, strictly speaking, according to USDA definitions—is how we separate out those different levels of food insecurity. And what makes one different from the other is the anxiety that individuals feel around food and their access to food, also the quality of food, and the quantity of food. So if you can imagine that those individuals who have very low food security, so the lowest below or, alternatively said, the highest food insecurity, those are individuals or households where there is anxiety about where the next meals are coming from. There will be a decreased quality of food, and there is a decreased quantity of food. So, these are individuals or households that actually cut out meals.
People with low food security may maintain the quantity of food, but the quality of food is going to be diminished. So, typically those are individuals who will keep themselves from feeling hungry by putting in lower-quality foods into their belly. And that's just simply to deal with the hunger. Again, that's often because those lower-quality foods tend to be less expensive as well, which is, you know, a whole other issue that I hope we can touch on briefly today.
There's also marginal food security, and those are individuals that may still have enough quantity, and quality itself may be variable, but they still will have occasional anxiety about whether they can put food on their table and on the table of their families as well...so various different levels of that [food insecurity].
I do want to also introduce another term, and that's nutrition insecurity. And that's important to getting at our increased understanding of the role that the quality of food and the nutritional value of food plays in our overall well-being and our health. So, there are individuals at all food security levels—frankly, even those of us who have high food security, those of us who can afford to buy food, that still may be making some poor nutrition choices. But that's another term I wanted to introduce. Most of our conversation today, I think, is going to be around food insecurity.
DG: Thanks for that definition, Suja, it’s very interesting. The anxiety component that you brought up with these definitions of food insecurity is very interesting, and I never heard that term “nutrition insecurity”, either!
SM: Let's talk a little bit about that anxiety. It's not hard for any of us to imagine. Just think about “I'm a parent.” Many of our listeners, I think, will be parents. Imagine the stress that a parent feels when they can't provide something for their children...and then imagine what degree of stress and anxiety would result from not being able to provide something so basic as food. As a parent, wondering if they're going to be able to feed their children—that's a tremendous source of anxiety. And living under that constant anxiety and stress, uncertainty about feeding oneself, and certainly of feeding others who depend on you, is very difficult. And if we stop and think about it, I'm quite sure we can all understand that very well.
[11:10] DG: Absolutely. As we were studying for this episode, one thing we were surprised about was how prevalent food insecurity is in the United States. According to the 2018 report by the United States Department of Agriculture (USDA), about 11.1% of US households are food insecure. And even though the prevalence of food insecurity has declined for the first time since 2007, 11.1% is a significant amount.
SM: Sure is, absolutely...That’s one in 10 on a good day, right? It's more than one in 10! And if you think about a group back when we were gathering together in larger groups to go to the grocery store, you look around, that's one in 10 people may not be able to predict where their next meal is going to come from. Or you go to the park or you walk down the street...that's one in 10 people who may be going to bed hungry tonight. So it is startling, and it ought to be startling, it ought to evoke that kind of emotion from all of us. And having said that, DJ, what you pointed out is absolutely true. Some of the numbers that we saw in 2018, and actually into 2019, were the lowest food insecurity rates that we had seen in about a decade. So in 2019, there were about 35 million Americans who are food-insecure. That's about one in nine people. Among children, it's about one in seven children that lived in a food-insecure household.
So in 2019, the rates were even slightly better than the one that you reported for 2018. But still, that's a pretty unacceptable rate, if you ask me. Even at that time, in 2019, it's also important to note the level—degree, rather—of disparities that existed across racial and ethnic lines around food insecurity. So a white non-Hispanic person living in America is likely to be food-insecure, one out of 12. Okay? So one out of 12 white non-Hispanics would be food insecure. However, if you're Latino, your likelihood would be one out of six. If you're black, non-Hispanic, it's one out of five. And if you're Native American, it's one out of four. 25% of Native Americans in 2019—again, the year, the best year we had in a very long time—were still food-insecure. And then the pandemic hit...so that really made everything a whole lot worse. We went from about 35 million to an estimated over 50 million. We don't quite know the exact numbers at this point as we're still early in the following year and we need to collect our data, but an estimated over 50 million Americans experienced food insecurity last year during the pandemic. And we spoke about the racial inequities that existed pre-pandemic. I'm sure our listeners are familiar with how COVID, and not just the medical, sort of, disease aspects of COVID, but also the economic impact of COVID, disproportionately affected some of our black and brown citizens of America. So that was definitely true during the pandemic, and its effect on food insecurity was felt as well.
RC: Yeah. So something that you mentioned that is so important is about the difference that exists between racial minorities and food insecurity and more flourished during the pandemic time, that we saw an increased rate- as you mentioned probably 50 million, that we don't know, exactly the data, but that's very important.
Something very important is the discrimination or racism for minority communities during the pandemic that just exacerbate all of the problems that we knew that existed in the past, but just were flourishing during this time.
One of them was food insecurity. Not getting the good and correct food. As you mentioned, the term “nutrition insecurity” to the house because there was not enough money to bring [home].
[16:15] RC: I want to ask you a question about what are the psychological and physical impacts of food security, for childrens and adolescents, and later on, if you can talk about the same thing in adults.
SM: Yeah. Yeah, thanks Ricardo. Yeah, absolutely. Food insecurity affected populations differently across the U.S. in the setting of the pandemic. And, it has a lot to do with poverty and patterns of poverty across our people groups. And we see the effect of food insecurity in children and in adults, non-senior adults as well as senior adults.
So to address your first question around children, it's really both physiologic and psychologic effects of food insecurity. So what we know, and the research is rather clear, is that when children are food-insecure, they experience more behavioral problems, difficulty in learning. And so, they tend to be slower in educational advancement.
They experience more depression. When children are experiencing more depression, they're experiencing more anxiety as well. They're experiencing more aggressive behavior. And then, other physiologic aspects, growth retardation, depending on when they're going to experience the food insecurity, that is going to manifest differently. So if it's in utero and early childhood, it's going to manifest with greater growth retardation later in childhood. It is going to manifest, not just in sort of the classic growth retardation and other super-low-nutrient manifestations, but also importantly, if we go back to what we know about quality of food and how people will sacrifice quality of food to maintain quantity of food, you're also seeing children that are eating more processed, less expensive food and experiencing, even in childhood, the diseases that you, Ricardo, as an endocrinologist, are very familiar with, right? Obesity and diabetes. So it's affecting children psychologically, educationally, and physiologically. It's really something that we all should care about, as citizens. And adults as well. When adults experience food insecurity, there is clearly a mental component of that, a psychological [component]. You can imagine, again, back to that trauma and anxiety of not being able to provide food for yourself or for people who depend on you. That's definitely there. So greater anxiety, greater depression.
And there is a correlation between food insecurity and diet-related illnesses. So diet-related illnesses, the greatest, collectively, the greatest reason for morbidity, mortality, and health expenditure here in the US. So diabetes, heart disease, hypertension, certain cancers, certainly obesity, all correlate with food insecurity.
So for some folks, it's hard to imagine that hungry people are also obese people. But in fact, it's two sides of the same coin, and it gets back to this idea that quantity can be maintained when, although quality may be sacrificed.
RC: The prevalence of obesity in childhood has been increasing exponentially in the last 30 years. And one of the reasons is that we always think that obesity is a disease of the rich. [In] first [world] and developing countries, obesity is a disease of the poor because they are the ones that cannot buy the good—as you mentioned—the good-quality food. But they have to buy food that will make them happier.
That is high-carbohydrate food, and they will be a little bit full for the rest of the day. So, that's so important to take into account when we talk about nutrition and food insecurity.
SM: You know, Ricardo, I recently heard a statistic that, actually, malnourishment, and meaning, not enough food. So, what we're seeing across the world is this shift towards problems of obesity.
DG: With these poor-quality foods, oftentimes these are the ones that are most often advertised within these communities. I noticed this, in certain communities, that you don't have a Whole Foods or a place that necessarily sells nutritious food at a cheap price. Sometimes there'll be several gas stations in the area, several fast food restaurants as well. So, I can imagine that's something that's contributing to this problem.
SM: Oh, absolutely. So food deserts, DJ, that's the term that's been used to describe certain areas of both urban areas and rural areas. Where it's difficult to get healthy, nutritious food, particularly fresh produce. So, it's definitely a problem in certain communities, within that community itself, and even transportation options to get out of that community and get to retailers that would sell [fresh produce]. It's limited, and it makes it...there are just so many dynamics at play there, but absolutely. Even if an individual wants to eat healthy, if they know how to eat healthy, if they have the education to know what is healthy, and they have the desire to actually eat those healthy—let's say produce is the best example of—eating fresh produce as a healthy, nutritious alternative.
It's very difficult to access in certain communities. If you're limited in what's in your community, if you're limited in terms of transportation to get to a place that will sell that to you. Yeah. And then of course, if you can afford it, because many of those healthful foods are simply more expensive than these high-carb processed foods that also have a much longer shelf life. So, it seems like a more economically wise decision to buy the poor-quality food.
[23:32] DG: Wow, there was so much in this episode. I know I was surprised to learn just how prevalent food insecurity is in the US and how much it affects not only the physical health of our patients, but their psychological health as well.
DG: We have much more to talk about in part 2 of our Food Insecurity Series, so I encourage you to check it out! Remember to go to our website www.thedeishift.com for show notes, additional resources, and more episodes. Follow us on Instagram and Twitter @thedeishift. Thank you for tuning in, and we will see you at part 2 of our Food Insecurity Series.
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