Hunger hits home
In an op-ed in the San Francisco Chronicle, family physician Laura Gottlieb told the story of an 8-year-old boy whose family she’d known for years. Brought to her office because of abdominal pain, the boy underwent multiple tests, including urine and stool examinations, blood work, and imaging studies. As soon as one test came back, Dr. Gottlieb ordered another. All were negative, and no cause for GI distress was found.18
Only later did she discover that hunger was the source of the pain. “It had never even occurred to me to ask his mother about how much food there was in the house,” Dr. Gottlieb wrote.18
In a similar vein, CBS News recently ran a story about a high school football team that seemed to be down on its luck. Besides being on a losing streak, many of the players were lethargic. Eventually, an astute coach realized that a mental pickup wasn’t what the team members needed—nutrition was. In this impoverished Burke County, Georgia school, about 85% of the student body qualify for in-school breakfast and lunch. But for many kids, those 2 meals were all they had to eat.19
With the help of a school nutritionist and the federal Healthy Hunger-Free Kids Act, hundreds of students now receive dinner, too. And last season, in late 2011, the properly fueled team members went on to win the state championship.19
Who is “food insecure”? In 2010, the latest year for which figures are available, 14.5% of US households (representing a total of 48.8 million people) were “food insecure,” as the problem of having too little to eat is officially known.20 Most of these families managed without substantially disrupting their normal eating patterns or reducing their intake, the US Department of Agriculture reports. This was accomplished by cutting back on the variety of foods they ate, getting federal food assistance, or getting food from food banks, among other coping strategies. But for 6.4 million households, the problem was severe enough to disrupt normal eating patterns and cause those affected to eat less than usual at least part of the time in the course of the year.20
Here, too, the toll on children is especially high. Twenty percent of households with children face food insecurity, nearly twice the rate of childless households.20 In a child’s earliest years, too little energy, protein, and other nutrients can result in long-lasting deficits in social, cognitive, and emotional development; malnutrition and deficiencies in vitamins and minerals may even result in brain impairment.18 In addition, school-age children who don’t have enough to eat have more behavioral problems and are more likely than those who are not struggling with hunger to be in special education classes.17
The hunger and obesity link
Ironically, hunger is also associated with obesity. High calorie, high carbohydrate foods like pasta and bread typically cost considerably less than nutrient-rich low-carb foods like cheese, fruit, fish, and vegetables, and are more filling. And in poor neighborhoods, food that is high in carbohydrates and low in protein and other nutrients tends to be more available than fresh, healthy—and more perishable—food.21
What’s more, people living in poverty may find it especially difficult to exercise. In many neighborhoods, exercising outdoors can be dangerous, gyms are unaffordable, and safe parks and playgrounds may be few and far between.21
Identifying poor and hungry patients
In a survey conducted by the Childhood Hunger Initiative of Oregon, most of the nearly 200 physicians and nurse practitioners who responded expressed a desire to learn more about the consequences of hunger and how to address them. Besides being uncomfortable broaching the subject of hunger and other poverty-related issues, the providers cited time constraints as a barrier to doing so.22
Ask this question
Citing similar obstacles, Canadian researchers conducted a pilot study in search of an easy-to-use, evidence-based “case-finding” tool. They offered questionnaires to patients at 4 clinics in British Columbia to determine which questions had the highest likelihood of determining whether an individual was struggling with hunger, poverty, or homelessness. Participants, which included patients above (n=94) and below (n=51) the poverty line, were also asked how they felt about being asked such questions.23
One particular question—“Do you (ever) have difficulty making ends meet at the end of the month?”—proved to be the best predictor of poverty. Although 2 additional questions about food and housing were identified as suitable for a 3-item screening tool, this single question alone had 98% sensitivity and 60% specificity (odds ratio, 32.3; 95% confidence interval, 5.4-191.5). Equally important, 85% of study participants with income below the poverty level thought that poverty screening was important, and 67% said they felt comfortable talking to their family physician about it.23