Research finds gaps in measures screening for hunger in hospitals

Claire Dugan organizing food shelves at Comer Feed1st food pantry

American Academy of Pediatrics (AAP) guidelines for screening hospital patients or their caregivers to see if they have enough food missed a quarter of people living in "food insecure" households, according to research by the University of Chicago Medicine published Thursday.

Food insecurity, defined as a condition of "limited or uncertain availability of nutritionally adequate and safe foods," is a prevalent health problem affecting one in eight U.S. households. In hospitals, the problem is even more prevalent and can interfere with medical care. Researchers aimed to validate AAP screening guidelines, as the group was one of the first and most influential medical organizations to recommend healthcare-based screening for hunger.

"I continue to be surprised by the prevalence of food insecurity," said Jennifer Makelarski, PhD, MPH, the study's first author. "We know nearly a third of parents of hospitalized children do not get enough to eat while their child is hospitalized. The hospital setting can create barriers to accessing food that a household doesn't typically experience: for example, higher cost of food and unwillingness to leave a child's side to get a meal."

First in 2015, and reaffirmed in May of this year, the AAP recommends health care providers use a screening tool with two "yes" or "no" questions designed to gauge food insecurity in children's households. To inform whether the tool should be adopted into clinical practice, the UChicago Medicine research team surveyed 188 eligible adults in adult and pediatric emergency departments between July and November 2016, using the AAP's two-item tool along with two additional, more detailed screening tools. One of the additional tools, the Hunger Vital Sign (HVS), was developed by Children's HealthWatch (a group that monitors how economic conditions and policies impact the health of young children) with other collaborators. The HVS tool contained the same two questions as the AAP tool but offered alternative answer options of "often true," "sometimes true" or "never true." Finally, a third, more detailed screening tool was used to test the accuracy of the AAP and HVS screeners.

"It's important that if we ask these questions, we ask the right questions so we don't miss the opportunity to help people who are food insecure," said Makelarski.

The best tool, the researchers determined, is the HVS tool that was developed in collaboration with researchers and individuals at Children's HealthWatch at Boston Medical Center. In the study, the HVS screen picked up about twenty percent more food insecure adults than the AAP tool. In their May 31, 2017 statement the AAP reiterated their initial "yes-or-no response" screening tool recommendations but also recommended an online toolkit that uses the HVS screener.

Stacy Tessler Lindau, MD, MA, professor of obstetrics/gynecology and medicine, is the study's senior investigator and took special notice of the food insecurity issue years ago when a chaplain at UChicago Medicine's Comer Children's Hospital brought it to her attention. Lindau, along with a group of medical students and other staff and faculty, formed food pantries at the children's hospital in 2010 through a program called Feed1st. While she knew many outside hospital and clinic pantries require prescriptions or vouchers to gain access, Lindau said the pantries in Comer Children's have round-the-clock self-serve access for patient families.

"Hunger is stigmatizing," said Lindau. "People should not have to give proof of need to access a hospital-based food pantry. People who use the pantry find ways to contribute back to the pantry in some way if they can. People who don't need the food don't take it and some are also inspired to contribute." Implementing screening for food insecurity in a hospital's regular workflow could help health systems address the food insecurity problem, the researchers said. By routinely asking about it, the problem of hunger becomes less stigmatizing and lets caregivers and patients know they can talk to health care providers if they are having difficulty accessing enough food.

"In a rich city like Chicago people should not be hungry," said Lindau. "Food is a basic human need. Hunger calls into question the value of the very expensive medical care we deliver."

And the hospital setting is just the tip of the iceberg.

"While hospital-based pantries do provide important relief in the hospital setting, most hungry people are not in the hospital most of the time," she said. "Integration of health systems with community-based hunger relief systems will promote the optimal impact of each."

The research, "Diagnostic Accuracy of Two Food Insecurity Screeners Recommended for Use in Health Care Settings," is published in the Sept. 21 edition of the American Journal of Public Health.