insights

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Experiencing food insecurity with insufficient access to healthy foods has been associated with negative health outcomes, including an increased vulnerability for micronutrient deficiencies¹ and a higher probability of developing chronic diseases.^2-4 While higher rates of chronic disease have been reported for both low-income and food-insecure adults,⁵ studies indicate that food security status may be more strongly predictive of chronic illnesses.^3,6

Nutrition interventions are essential therapeutic strategies for combatting many chronic diseases, yet limited access to affordable, varied, and nutritious foods, as seen in food deserts, may impede healthcare efforts. In functional medicine, a personalized, nutrition-based strategy to address chronic disease starts with a comprehensive nutrition evaluation and hearing the entirety of a patient’s story. Understanding the conditions in which a patient lives and their potential social, economic, and personal barriers is a crucial component in the development of sustainable and effective interventions.

Food Insecurity and Chronic Disease

Food insecurity occurs when access to sufficient amounts of nutritious, affordable food is blocked or interrupted due to a lack of money or other resources, resulting in a disruption of eating patterns and nutrient intake.⁵ As part of the US government’s prevention agenda outlined in the Healthy People 2030 report, food insecurity is a key issue discussed,⁵ and USDA national statistics from 2021 indicate that:

• 10.2% of US households (approximately 33.8 million people) were food insecure at least some of the time during the year.^7,8
• Rates of food insecurity increased for some population subgroups, including households with no children (from 11% in 2020 to 13.2% in 2021) and for older adults living alone (from 8.3% in 2020 to 9.5% in 2021).⁷
• Rates of food insecurity decreased significantly for all households with children (from 14.8% in 2020 to 12.5% in 2021) and for other population subgroups such as single mothers with children (from 27.7% in 2020 to 24.3% in 2021).⁷
• For adults living in families, those who self-reported as non-Hispanic other and multiple races (12.7%) and non-Hispanic Black (12.2%) experienced higher rates of food insecurity compared to those who self-reported as non-Hispanic white (4.1%) and non-Hispanic Asian (3.7%).⁸

Observational studies have associated food insecurity with increased odds of self-reported poor health and development of chronic diseases such as obesity, diabetes, and hypertension for young and older adults.^4,5 In addition, a 2022 cross-sectional analysis of data from the 2017-2018 National Health and Nutrition Examination Study (n=3,502 participants aged 20 years or older) indicated that food insecurity was associated with higher liver stiffness measurements for those adults over 50 years of age and may increase the risk of advanced fibrosis and cirrhosis in older adults.⁹ Further analysis of US statistics have also suggested that food insecurity is associated with greater all-cause mortality in adults with non-alcoholic fatty liver disease and advanced fibrosis.¹⁰

Analysis from a USDA National Health Interview Survey indicated that the number of chronic conditions for adults in food-insecure households was, on average, 18% higher than for those in food-secure households.³ Further, the analysis found that food security status of adults was also strongly related to the number of chronic conditions reported, and lower food security was associated with a higher probability of all the chronic diseases examined in the report:³

• Hypertension
• Coronary heart disease (CHD)
• Hepatitis
• Stroke
• Cancer
• Asthma
• Diabetes
• Arthritis
• Chronic obstructive pulmonary disease (COPD)
• Kidney disease

And children are not exempt from these negative health impacts. A 2020 review published in Pediatric Clinics of North America reported that children experiencing food insecurity with limited access to healthy foods demonstrate poorer eating behavior that may lead to the development of chronic disease.¹¹ Food-insecure children may manifest with many different ailments, including anxiety and depression, and have an increased prevalence of anemia, asthma, and hospitalization with diabetes.¹¹

Food Deserts

Living in a food desert directly impacts consistent and reliable physical access to healthy foods. According to the Office of Disease Prevention and Health Promotion, reports indicate that more than 23 million people are estimated to live in food deserts in the United States.¹² These food deserts are neighborhoods that have fewer full-service supermarkets, and food-desert residents may have to travel long distances to reach grocery stores while potentially having limited vehicular access or public transportation options.^5,12,13 Convenience stores and small independent stores that may lack adequate variety, quantity, and consistency of affordable, nutritious foods are more common in food deserts than full-service supermarkets, and national reports suggest that overall, predominantly Black and Hispanic neighborhoods have fewer grocery stores than predominantly white and non-Hispanic neighborhoods.⁵

A 2015 observational study based on a national health survey with over 22,000 participants found that those residing in a food desert had lower levels of serum carotenoids, a biomarker of fruit and vegetable intake, compared to those not in food deserts, and had higher systolic blood pressures.¹⁴ Of note, those participants with lower incomes also had greater odds of developing chronic kidney disease (CKD).¹⁴ A 2023 retrospective cohort study (n=777,994 individuals living in Chicago, Illinois) investigated associations between food access measured by household distance to a supermarket and the incidence of hypertension, diabetes, and CKD.¹⁵ Compared to the shortest distance, significant associations were found between longer distances and increased odds for developing the mentioned chronic diseases.¹⁵

HealthCare Costs

Food insecurity has also been associated with greater subsequent healthcare expenditures. A 2018 longitudinal study using data from 2011 through 2013 estimated that food-insecure adults had significantly greater estimated annual healthcare costs, at an extra $1,863 individually, or extrapolated to $77.5 billion in additional annual healthcare expenditures in the US.¹⁶ An updated 2020 report using US data from 2016 reported that households with marginal, low, or very low food security were increasingly more likely to have any healthcare expenses and to have higher levels of total healthcare expenses than food-secure households.¹⁷

Clinical Applications

In functional medicine, a robust patient-practitioner relationship is not only important to empower the patient in their health journey but also to meet the patient where they are in order to develop the most effective treatment plan to combat their chronic illness, boost their immunity and resilience, and support them on their path to optimal wellness.

This collaborative relationship begins from the initial clinical intake assessment, nutrition evaluation, and documentation of the patient’s story through IFM’s Timeline and Matrix tools. Understanding a patient’s cultural needs and preferences, for example, may help inform nutrition-based therapies, modifying therapeutic food plans so that they are more accessible to the patient and reflective of traditional diets. In addition, considering certain factors, such as potential food insecurity and the possible resulting impacts of micronutrient deficiencies, elevated stress levels, and food accessibility barriers, may help inform the speed and breadth of treatment steps and implementation strategies.

Learn more about building collaborative relationships with patients, nutrition evaluations, and understanding your patient’s health stories at IFM’s upcoming Applying Functional Medicine in Clinical Practice (AFMCP) course.

Related Articles and Podcasts

The Hidden Hunger: Micronutrient Deficiencies

Supporting Health in Underserved Populations

Barriers to Immune Resilience

References

1. Drake VJ. Subpopulations at risk for micronutrient inadequacy or deficiency. Linus Pauling Institute, Oregon State University. Published March 2018. Accessed May 22, 2023. https://lpi.oregonstate.edu/mic/micronutrient-inadequacies/subpopulations-at-risk
2. Laraia BA. Food insecurity and chronic disease. Adv Nutr. 2013;4(2):203-212. doi:3945/an.112.003277
3. Gregory CA, Coleman-Jensen A. Food insecurity, chronic disease, and health among working-age adults (ERR-235). USDA Economic Research Service. Published July 2017. Accessed May 22, 2023. https://www.ers.usda.gov/publications/pub-details/?pubid=84466
4. Nagata JM, Palar K, Gooding HC, Garber AK, Bibbins-Domingo K, Weiser SD. Food insecurity and chronic disease in US young adults: findings from the National Longitudinal Study of Adolescent to Adult Health. J Gen Intern Med. 2019;34(12):2756-2762. doi:1007/s11606-019-05317-8
5. Office of Disease Prevention and Health Promotion. Healthy People 2030: food insecurity. US Department of Health and Human Services. Accessed May 30, 2023. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/food-insecurity
6. Cai J, Bidulescu A. The association between chronic conditions, COVID-19 infection, and food insecurity among the older US adults: findings from the 2020-2021 National Health Interview Survey. BMC Public Health. 2023;23(1):179. doi:1186/s12889-023-15061-8
7. Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household food security in the United States in 2021 (ERR-309). USDA Economic Research Service. Published September 2022. Accessed May 26, 2023. https://www.ers.usda.gov/webdocs/publications/104656/err-309.pdf?v=4735
8. Weeks JD, Mykyta L, Madans JH. Adults living in families experiencing food insecurity in the past 30 days: United States, 2021. NCHS Data Brief. 2023;(465):1-8. https://www.cdc.gov/nchs//data/databriefs/db465.pdf
9. Tapper EB, Mehta M, Leung CW. Food insecurity is associated with chronic liver disease among US adults. J Clin Gastroenterol. 2022;10.1097/MCG.0000000000001741. doi:1097/MCG.0000000000001741
10.  Kardashian A, Dodge JL, Terrault NA. Food insecurity is associated with mortality among U.S. adults with nonalcoholic fatty liver disease and advanced fibrosis. Clin Gastroenterol Hepatol. 2022;20(12):2790-2799.e4. doi:1016/j.cgh.2021.11.029
11.  Pai S, Bahadur K. The impact of food insecurity on child health. Pediatr Clin North Am. 2020;67(2):387-396. doi:1016/j.pcl.2019.12.004
12.  Office of Disease Prevention and Health Promotion. Healthy People 2030: Access to foods that support healthy dietary patterns. US Department of Health and Human Services. Accessed May 30, 2023. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/access-foods-support-healthy-dietary-patterns
13.  Brandt EJ, Silvestri DM, Mande JR, Holland ML, Ross JS. Availability of grocery delivery to food deserts in states participating in the online purchase pilot. JAMA Netw Open. 2019;2(12):E1916444. doi:1001/jamanetworkopen.2019.16444
14.  Suarez JJ, Isakova T, Anderson CA, Boulware LE, Wolf M, Scialla JJ. Food access, chronic kidney disease, and hypertension in the U.S. Am J Prev Med. 2015;49(6):912-920. doi:1016/j.amepre.2015.07.017
15.  Garg G, Tedla YG, Ghosh AS, et al. Supermarket proximity and risk of hypertension, diabetes, and CKD: a retrospective cohort study. Am J Kidney Dis. 2023;81(2):168-178. doi:1053/j.ajkd.2022.07.008
16.  Berkowitz SA, Basu S, Meigs JB, Seligman HK. Food insecurity and health care expenditures in the United States, 2011–2013. Health Serv Res. 2018;53(3):1600-1620. doi:1111/1475-6773.12730
17.  Dean EB, French MT, Mortensen K. Food insecurity, health care utilization, and health care expenditures. Health Serv Res. 2020;55(Suppl 2):883-893. doi:1111/1475-6773.13283