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Department of Health Studies, College of Arts & Sciences, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016, United States of America
Department of Health Studies, College of Arts & Sciences, American University, 4400 Massachusetts Avenue NW, Washington, DC 20016, United States of America
), is a social and economic condition with health consequences across the lifespan including poor dietary intake, physical health, and increased risk for chronic diseases and mental health conditions (
). Mental illness is more prevalent among individuals who experience food insecurity; furthermore, mental health conditions and food insecurity co-occur disproportionately among more women than men (
). In the US, almost fifty million individuals are food insecure, of which nearly 20% are children. Food insecure households spend 45% more annually on medical care than those in food secure homes (
), further demonstrating the acute interconnectivity of the social, economic, and medical experiences of low-income American communities.
Food system inequities drive both hunger and chronic disease risks. Additionally, disadvantaged communities are most impacted by mental health conditions, which compounds the effects of socio-economic determinants throughout the lifespan (
). Food purchasing decisions are influenced by travel time to shopping, availability of healthful foods, availability of personal funds, and food prices (
). Individuals living in food deserts and food swamps face barriers to accessing healthy and affordable food. A food desert is defined as a low-income community with limited access to affordable and nutritious food and are often characterized by measuring the distance between people's homes and supermarkets (
). Communities where fewer supermarkets are available also tend to have a higher number of corner stores, which typically stock energy-dense, shelf-stable foods that are nutrient-poor foods (
demonstrated that food swamps are a stronger predictor of obesity rates among adults than food deserts, suggesting it is necessary for food environment descriptions to include the availability of both healthy and unhealthy food quality to accurately depict the nutrition environment low-income communities encounter on a daily basis.
Food insecurity specific to mental health
The number of Americans assessed to be food insecure has been variable, with reports of between 35 to more than 50 million, and impacted by race, geographic location, employment status, poverty level, level of education attained and societal drivers such as the recession of 2008–2010 and the current COVID pandemic (
). In school-age children, hunger impacts their ability to concentrate which results in lower academic performance, complaints of headaches and stomachaches and can contribute to disruptive behaviors (
Moderation of the association between individual food security and poor mental health by local food environment among adult residents of Flint, Michigan.
). In adults, food insecurity has been associated with shame, despair, anxiety and depression, hopelessness, chronic stress, inability to afford and use mental health services and a variety of worrisome behaviors associated with obtaining food (
Moderation of the association between individual food security and poor mental health by local food environment among adult residents of Flint, Michigan.
Socially-mediated approaches to address food insecurity
The complex interactions between food insecurity, poverty, and chronic disease prevention and management (including the treatment and management of mental illnesses and experiences) requires an understanding of the non-medical drivers of health. Equity in food security is integrally connected to health, employment, housing, and education; these concepts are often characterized as “the social determinants of health (SDH).” A two-way path exists between mental illness and social determinants; poor mental health can influence a person's experience of social determinants while social determinants can moderate a person's experience of mental health (
). Thus, socially-mediated approaches may be effective at improving nutritional and clinical (and, perhaps, sub-clinical) outcomes. Access to affordable, nutritious food can improve health and decrease risk of chronic diseases; however, food security includes both the access to food and the nutritional quality of food as the foundation to overall health and wellness. Access to healthy food may not be enough to prevent chronic diseases, as individuals require additional support to access food, adopt dietary patterns, and change behaviors (
). Community health programming and larger public health efforts attempt to tackle outcomes by addressing these interconnected SDH.
Food insecurity and low income status, along with their concomitant health-compromising coping strategies, can exacerbate existing mental health and other chronic conditions. For example, engaging in cost-related medication underuse or non-adherence (e.g., skipping medications, taking less medication than prescribed, delaying prescription refills, using lower cost medications) (
) exacerbate those same health conditions. The complexity of these issues requires comprehensive and interconnected health approaches that account for emotional and psychological vulnerabilities.
Although the evidence is consistent and compellingly supports the effectiveness of improved access to food programs and the improvement of a variety of health outcomes, gaps in confirmation of the effectiveness of combined, public health strategies with multi-sectoral partnerships exist (
). Comprehensive, socially-mediated interventions have the potential to transform perceived nutritional ‘barriers’ – such as lack of coordination across medical, community health, and social programming – into integral components of education- and self-efficacy-focused nutritional interventions, empowering patients to navigate the complexities of the food and health-mental health care continuum and assisting them in this dynamic process.
One such intervention, care coordination, goes beyond service provision. Populations that are being treated with medications such as antidepressants or antipsychotics may, individually, have differential side effects related to their medication use. For example, known associations exist among use of antipsychotics and diabetes status (
). Personalized interventions targeting the uniquely complex factors experienced by individuals utilizing pharmacological treatments for mental illness, such as lifestyle interventions that target medication-related weight gain (
), could address the nexus of mental health, nutrition, and chronic health outcomes directly.
Building community partnerships
Health care and food access programs can serve as partners in efforts toward health promotion, improving food security, and the prevention and management of chronic diseases, including mental illness. Many food banks in low-income communities have developed supply chains for fresh produce or even grow their own fruits and vegetables (
Challenges and opportunities to increasing fruit and vegetable distribution through the US charitable feeding network: Increasing food systems recovery of edible fresh produce to build healthy food access.
). Other health advocates promote chronic disease management by offering education such as chronic disease self-management in hospital and clinic settings (
). A recent intervention trial, which bundled healthy food allotments with diabetes self-management education delivered at 27 food pantries, improved food security and intake of fruits and vegetables (
). Additional community intervention efforts to reduce nutritional health risks include referrals to resources such as federal nutrition programs or food pantries, assistance with nutrition benefits and enrollment, food from on-site gardens, meal delivery programs, food-as-medicine programs, and produce vouchers that can be redeemed at farmers' markets (
). These community-based partnerships have shown promising preliminary results to increase food security among low-income populations.
Leveraging nursing practice for nutritional health
Nursing's role in addressing food insecurity
Nurses can play a vital role in promoting health equity and addressing SDH as it relates to food insecurity. A team-based approach is necessary to address SDH in the health care setting. The relationship between the food environment, neighborhood factors, and health outcomes must be considered when counseling patients on their risk of obesity and other chronic conditions. Nurses have the opportunity to promote health and the prevention of chronic diseases by incorporating food security/insecurity questions in routine medical and mental health assessments and through nutrition education. Although nurses of all sub-fields may have limited time to engage in nutrition education, nurses can advocate for or directly refer to nutrition programs to cover these necessary and relevant services. Nurses can help to identify food insecure individuals, facilitate access to community resources, and advocate for food and nutrition polices that address SDH. From a patient-care perspective, need exists for seasoned healthcare providers, like nurses, that typically provide health education to patients to provide nutrition education tailored for the unique lived experiences of, say, mentally ill or cognitively impaired populations. Strategies for providing nutrition education among those with serious mental illness are few but growing (
Despite the growing recognition of the importance of SDH, there is a lack of evidence for effective scalable strategies to address social determinants, particularly in low-income communities and among vulnerable individuals who are mentally ill (
). Given limited food system access, limited time of clinicians, and the challenges inherent in the lives of low-income individuals, investment in interventions are necessary if nurses are going to be a significant partner in efforts to reduce the steady rise in chronic diseases. The necessity to reduce health disparities in chronic diseases has led to an increased interest in nurse-led interventions in the US. Nurse-led interventions have demonstrated promise in improving health behaviors. A review of 39 effective intervention models (
) created by nurses found the majority focused on the following SDH imperatives: strengthening integration of health services and systems; fostering cross-sector collaboration to improve well-being; creating healthier, more equitable communities; and supporting health and well-being as a shared value among the health-care team. Indeed, across all effective interventions is the role of partnerships and weaving together program services all aimed at enhancing the health of vulnerable populations.
Moreover, in other evaluations of chronic disease management interventions targeting underserved populations, participating communities were not actively involved in the identification of needs or in developing, implementing, and evaluating those interventions, which may have constrained effectiveness and potential sustainability. While partnerships across programs and institutions is important, it is just as important to include vulnerable populations in the development of the services provided to them. An extended role of nurses within health care teams to lead interventions that address SDH has the potential to advance health equity using upstream approaches that are culturally competent, affordable, patient-centered (
). Food insecurity in the time of the COVID-19 pandemic illustrates the complexities of food inequity. In the US, approximately 35 million households rely on the Supplemental Nutrition Assistance Program (SNAP) (
); both Federally-funded programs help meet the needs of low-income children and families who are food insecure, at nutrition risk, and are currently practicing social isolation. Applications, certifications, and meal provisions for these programs have increased significantly since the COVID-19 pandemic began in the US in early 2020 (
). Some state SNAP, WIC, and child nutrition programs have applied for waivers to give beneficiaries more flexibilities in accessing and purchasing a wider range of foods and non-covered necessities to meet the needs of vulnerable households (
). Approximately 50 million children receive food and/or breakfast at school each day. States are responding to the increasing needs in different ways, but food access and distribution remains a central challenge to implementation of program services (
COVID-19 has exacerbated the long-standing and interconnected SDH in socioeconomically disadvantaged communities. Layered on top of food insecurity issues are a myriad preexisting diagnosed physical and mental health co-morbidities that burden minority and low-income Americans disproportionately. Low-income communities bear a disproportionate, pandemic-related burden due to increased food insecurity that persists beyond the cessation of initial social efforts to reduce the community spread of SARS-CoV-2. The World Health Organization has already reported on general increases of pandemic-related mental illnesses experienced by both the general population and the healthcare workforce (
), which underscores the interconnectedness of the COVID-19 pandemic, mental health, and the nutritional life of populations globally. Despite planned re-openings of society across the US in state-level “phased” processes, people with pre-existing mental illnesses will need to readjust their health management again, and those who have pandemic-related mental illness such as depression or post-traumatic stress will need access to mental health professionals.
Recommendations and strategic considerations using a food equity approach
The pandemic invites a shift in thinking about equity, particularly with regard to ensuring that basic needs of food, housing, and education are met. Furthermore, SDH are the result of structural inequalities in institutional systems, not individual patient vulnerabilities (
). This key distinction may be challenging for nurses and health care providers who deliver care on an individual basis. However, this necessary shift in framing is critical for changing attitudes and providing care to understand disadvantage due to long-standing structural inequalities. A shift in healthcare providers' perceptions of the community care networks within which they operate can spark creative integration and streamlining of mental health and nutrition services.
A “food equity approach” is an emerging framework for using policy to reduce health disparities. Efforts to address SDH and promote health beyond health care is growing, which is evident in the shift of American national health priorities. We are in the midst of an evolution from traditional, individual behavior approaches to innovative, systems approach that focuses on community health and multi-sector partnerships that relieve the burden of addressing all of society's ills from one healthcare provider. As such, system-focused approaches are necessary for engaging communities in support of societal level reforms to reduce food insecurity and better reap the value of community programs like SNAP and WIC.
The Equity-Oriented Obesity Prevention framework (
) is aligned with a public health approach to nursing. The framework has four quadrants with the top two identifying potential policy, systems and environmental changes: Increase Healthy Options and Reduce Deterrents. The two lower quadrants call out individual and community resources and capacity: Build on Community Capacity and Improve Social and Economic Resources (Fig. 1). Integrating evidence-based clinical and socially-mediated interventions may reduce the prevalence of food insecurity and create a sustainable impact.
Reprinted with permission from S.K. Kumanyika. A Framework for Increasing Equity Impact in Obesity Prevention. American Journal of Public Health, October 2019; 109(10): 1350–1357.
In addition to providing critical care, nurses are influential in delivering well-received messages. Nurses are trusted by patients for their knowledge and can directly support individuals who are food insecure in the following ways:
1.
Identify patients who are experiencing food insecurity using the validated two-question screening tool (
) that is based on the U.S. Household Food Security Scale to rapidly identify households or individuals at-risk.
2.
Deliver culturally-competent, effective nutrition education (such as an education curriculum like Cooking Matters) and promote health literacy.
3.
Connect at-risk patients with available Federal and state nutrition programs, such Head Start, SNAP, WIC, and others.
4.
Encourage individuals to participate in on-site nutrition education classes provided by local, state, or national service-providing non-profit organizations.
5.
Promote existing community resources and partnerships to increase access to healthy foods such as food shelters, food pantries, community kitchens, community gardens (especially at sites that offer needed services such as primary care, behavioral health, housing, and access to welfare supportive services).
6.
Share best practices among professional associations, data on food insecurity (through strategic use of data sharing agreements and system integration), and innovative interventions that have demonstrated effectiveness.
7.
Advocate at the local, state, and national level for policies that address food insecurity and its root causes, as well as those policies that strengthen partnerships across medical, mental health, and social program services.
Policy intervention approaches for addressing food insecurity
Policy interventions are needed to fully address the links between food insecurity and poor health outcomes, and that enable nurses to have maximum impact and effectiveness in addressing food insecurity. Policy intervention could take one of several approaches to improve the food environment in communities and impact rising obesity rates or a multi-pronged approach: 1) limit the availability or affordability of unhealthy foods; 2) promote access to healthy food options (
); 3) attract food retailers offering healthier foods in under-resourced communities; 4) construct policy-based programs that moderate excess costs of healthier foods for small, local retailers in underserved communities. However, some research has demonstrated that restricting unhealthy food without introducing alternative healthy food options may lead to higher rates of food insecurity (
) highlights the growing evidence of the effectiveness of interventions that simultaneously increase availability of healthy food and decrease availability of unhealthy food to maximize the potential of the food environment to promote health equity – key to effectiveness is simultaneously balancing incentives for healthier food and disincentives for unhealthier options.
Health care interventions often focus on one social determinant (e.g., food security) and evaluate clinical outcomes to determine effectiveness; however, it is imperative that future research examines multiple dimensions of social determinants and involves multi-sectorial partnerships, especially relevant for those with mental health conditions. There is a need for policy and clinical interventions that incorporate multiple risks of those who experience food insecurity and mental health conditions. Identifying social determinants that exacerbate the association between food insecurity and mental health can inform policy and clinical decisions that improve access to food and good mental health among the most vulnerable members of society.
Hospitals and health care systems can invest in interventions that directly address food insecurity and other SDHs by collaborating with communities they serve. Currently, several medical and health organizations are prioritizing efforts to address food insecurity as part of broader SDH work (
). Hospitals and clinics can leverage external outreach program partners to connect with underserved individuals to help inform community health needs assessments. Hospital- or clinic-based outreach programs can directly address non-medical individual needs in their service areas, including food access, by building collaborations and partnerships (with food assistance programs like SNAP, WIC, and school-based child nutrition programs), being advocates for their communities (through helping to shape community-oriented local policy), and raising awareness about the impact of the social determinants of health and food insecurity (through the development of events and resources available to the local community). Federally-Qualified Health Clinics (FQHCs) are an example of co-locating wrap-around services for the most vulnerable.
Further, the role of technology in service provision by the mental health nursing community can help empower health and nutrition education provided to individuals experiencing food insecurity (
). Through waivers allowing new service provision options during the pandemic, nutrition assistance programs like WIC had temporarily moved certification procedures, nutrition counseling and education, and health and social services referrals to online platforms and telecommunications (i.e. telehealth). In addition, hospitals and clinics typically collect important health information like height, weight, and hematocrit that programs like WIC use to tailor their food packages, nutrition counseling, and nutrition education. Partnerships between psychiatric nurses and WIC could, for example, help WIC nutritionists, dietitians, and staff identify nutritional risks to target among low-income pregnant women and mothers.
Likewise, WIC staff members could identify low-income mothers who are at risk for a number of mental health conditions and provide a direct referral (one of the important high-value benefits of WIC participation) to psychiatric nurses for care. Importantly, WIC staff already identify risks of mental health conditions such as depression and postpartum depression among mothers enrolled in the program (
). While WIC staff are trained to identify the numerous risks among low-income families eligible for WIC nutrition benefits, an Equity-Oriented Prevention Approach would leverage psychiatric nurses to support the unique healthcare needs of mothers and children affected by identified mental health conditions while WIC staff take care of supplemental nutrition need and education, thus creating a more tightly coordinated healthcare experience that places nutrition in focus and executes nutrition education in a patient-centered manner that acknowledges their psychological and psychiatric needs.
Nurses and health care teams can help lead efforts to address SDH and improve food security. Additional research on the role of nurses and their promotion of health will help us better understand the extent to which policy and community-based interventions are most effective at combatting food insecurity, particularly among those with mental health conditions. As part of a provider network, mental health nursing can play an important role in food security, nutritional health, and mental illness management among already deeply vulnerable populations.
Declaration of competing interest
The authors have no conflicts of interest to declare.
References
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What is the effectiveness of obesity related interventions at retail grocery stores and supermarkets? - A systematic review.
Moderation of the association between individual food security and poor mental health by local food environment among adult residents of Flint, Michigan.
Challenges and opportunities to increasing fruit and vegetable distribution through the US charitable feeding network: Increasing food systems recovery of edible fresh produce to build healthy food access.
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