Addressing)Hunger) Essential)to) Improving)Health)

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A)paper)developed)by:)

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March)2013

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! The!relationship!between!eating!well!and!good!health!is!solidly!acknowledged.!!We! learn!from!an!early!age!that!you!are!what!you!eat!and!consuming!fruits!and! vegetables!is!important.!!With!the!growth!of!the!obesity!epidemic,!much!of!the! attention!to!food!consumption!in!America!has!focused!on!the!volume,!caloric! density,!and!fat!content!of!food!consumed,!with!good!reason.!!Whats!often!missing! in!our!discussion!of!good!health!and!food!consumption,!however,!is!the!tragic!level! of!hunger!in!America.!!In!the!richest!nation,!millions!suffer!the!pangs!of!hunger!and! their!health!suffers!as!a!result.!!! ! In!this!white!paper,!we!examine!the!extent!of!hunger!in!America,!the!inextricable! links!of!hunger!to!poor!health,!and!the!need!to!consider!hunger!as!a!health!issue!to! make!the!changes!needed.! ! Prevalence)of)Hunger)in)America) ! Food!insecurity,!or!an!inadequate!intake!of!food!due!to!lack!of!resources,1!affected! almost!one!in!six!US!households!in!2011.!!Overall,!more!than!50!million!people,! including!almost!17!million!children,!suffer!from!food!security!issues!at!some!time! each!year.2!!In!addition,!almost!6!percent!of!households!experienced!very!low!food! security!marked!by!having!the!food!intake!of!one!or!more!household!members! reduced!and!eating!patterns!disrupted!at!times!during!the!year!due!to!a!lack!of! money!and!other!resources!for!food.!3!!Households!with!children!experienced!food! insecurity!at!much!higher!rates!than!those!without!children,!especially!singleOparent! households.!!Minorities!are!also!disproportionately!affected!with!more!than!one!in! four!Hispanic!and!black!nonOHispanic!households!reporting!food!insecurity.!! !

Addressing)Hunger)Essential)to)Improving)Health)

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1!RR!Briefel!&!CE!Woteki,!Development!of!the!food!sufficiency!questions!for!the!Third!National!Health!and!

Nutrition!Examination!Survey,!Nutr!Educ!1992;!24:24SO28S.! 2!A!ColemanOJensen,!M!Nord,!et!al.!Household!Food!Security!in!the!United!States!in!2011,!USDA!Economic! Research!Service,!Economic!Research!Report!No.!(ERRO141)!Sept.!2012.! 3!A!ColemanOJensen,!M!Nord,!et!al.!Household!Food!Security!in!the!United!States!in!2011,!USDA!Economic! Research!Service,!Economic!Research!Report!No.!(ERRO141)!Sept.!2012.!

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!!Map!the!Meal!Gap,!Food!Insecurity!in!Your!County

! ! As!the!map!above!illustrates,!hunger!is!a!national!problem!with!every!county!in!the! United!States!affected.!!Nationally,!between!2009O2011,!seven!states!had!statistically! higher!household!food!insecurity!rates!than!the!national!average:!Mississippi,!Texas,! Arkansas,!Alabama,!Georgia,!Florida,!and!North!Carolina.4!!In!Ohio,!the!food! insecurity!rate!is!also!higher!than!the!national!average!with!more!than!2!million! residents!experiencing!food!insecurity.!!In!several!counties,!more!than!1!in!5! Ohioans!faced!food!insecurity!in!2010.!!Lucas!County!had!one!of!the!highest!rates!of!

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4!A!ColemanOJensen,!M!Nord,!et!al.!Household!Food!Security!in!the!United!States!in!2011,!USDA!

Economic!Research!Service,!Economic!Research!Report!No.!(ERRO141)!Sept.!2012.!

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food!insecurity!with!almost!one!in!five!residents!O!or!more!than!85,000!people!O! facing!hunger.5!!! ! Hunger)and)Health) There!are!clear!associations!between!food!insecurity!and!poorer!health!status! among!adults!and!children.!!Food!insecurity!is!associated!with!lower!scores!on! physical!and!mental!health!exams.6!!! Research!shows!that!adults!living!in! foodOinsecure!households!consume! fewer!servings!of!fruits,!vegetables,!and! dairy!and!nutrients!such!as!B!vitamins,! magnesium,!iron,!zinc,!and!calcium.! These!dietary!shortfalls!are!linked!to! the!development!of!chronic!diseases,! including!hypertension,!hyperlipidemia,! and!diabetes.!7! Adults!experiencing!food!insecurity!are! also!at!greater!risk!of!developing!type!II! diabetes8!and!are!more!likely!to! experience!mental!and!behavioral!health!problems,!including!higher!levels!of! depression!and!anxiety.9!!Given!their!vulnerability,!the!elderly!and!children!suffer! the!greatest!impact.!! Among!the!elderly,!malnutrition!exacerbates!diseases,!increases!disability,! decreases!resistance!to!infection,!and!extends!hospital!stays.!Malnutrition!results!in! increased!costs!to!caregivers!by!increasing!caregiver!demands,!and!inflates!national! health!care!costs!due!to!increase!complication!rates.10!!Even!after!controlling!for! other!factors!that!affect!health!status,!elderly!experiencing!food!insecurity!were! more!than!twice!as!likely!to!report!having!fair!to!poor!health!status!as!their!peers! without!food!security!issues.!!Moreover,!six!out!of!ten!of!these!seniors!also!had! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 5!Feeding!America,!Map!the!Meal!Gap!2011.!!Interactive!map!with!food!insecurity!statistics!by!county!available!
online:!http://feedingamerica.org/hungerOinOamerica/hungerOstudies/mapOtheOmealOgap.aspx,!accessed!March! 6,!2013.! 6!JE!Stuff,!PH!Casety,!et!al.,!Household!Food!Insecurity!Is!Associated!with!Adult!Health!Status,!J!Nutr!2004;! 134(9):2330O2335.!!!
7!HK!Seligman,!BA!Laraia,!and!MB!Kushel,!Food!Insecurity!Is!Associated!with!Chronic!Disease!among!LowO

Income!NHANES!Participants,!J!Nutr!2010;!140(2):304O10.! Income!NHANES!Participants,!J!Nutr!2010;!140(2):304O10.!

8!HK!Seligman,!BA!Laraia,!and!MB!Kushel,!Food!Insecurity!Is!Associated!with!Chronic!Disease!among!LowO 9!R!Witaker,!S!Phillips,!&!S!Orzol,!Food!Insecurity!and!the!Risks!of!Depression!and!Anxiety!in!Mothers!and!

Behavior!Problems!in!Their!PreschoolOAged!Children,!Mathematica!Policy!Research!Reports!(2006).! Elderly!Persons,!J!Nutr!2001;!131(5):1503O509.!

10!JS!Lee!&!EA!Frongillo,!Nutritional!and!Health!Consequences!Are!Associated!with!Food!Insecurity!among!U.S.!

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functional!impairments!that!affected!activities!of!independent!living!or!their!ability! to!care!for!themselves.11!
Are)hunger)and)obesity)linked?) ! Though!obesity!and!food!insecurity!may!seem!like! independent!health!problems,!there!is!growing!awareness! that!the!two!issues!!though!seemingly!contradictory!O!may!in! fact!be!related.!!Studies!link!food!insecurity!to!poor!nutrition.! Research!also!shows!that!people!with!limited!resources!tend! to!spend!less!on!food!in!general!and!spend!less!on!healthy,! lower!calorie!foods!like!fruits!and!vegetables!in!particular.!! ! The!Robert!Wood!Johnson!Foundation!sponsored!a!synthesis! of!research!on!the!topic,!noting!several!interesting!linkages! and!even!more!questions.! ! According!to!the!study,!research!exploring!the!relationship! between!food!insecurity!and!obesity!are!limited,!show!mixed! results,!and!demonstrate!the!need!for!additional!research:! ! Women!who!experience!food!insecurity!are!more!likely! to!be!obese!compared!with!food!secure!women,!though!it! is!not!clear!whether!food!insecurity!promotes!weight! gain!over!time.! Research!on!men!and!food!insecurity!has!not! consistently!shown!a!relationship!between!food! insecurity!and!obesity.! Research!on!children,!food!insecurity,!and!obesity!has! yielded!mixed!results.!!Though!most!studies!on!these! topics!have!found!no!evidence!of!a!direct!relationship,!a! few!have!found!that!children!in!food!insecure!households! are!more!likely!to!be!obese.! !
Source:!N!Larson!and!M!Story,!Food!Insecurity!and!Risk!for!Obesity! Among!Children!and!Families:!Is!There!a!Relationship?!A!Research! Synthesis!Healthy!Eating!Research:!A!National!Program!of!the! Robert!Wood!Johnson!Foundation,!April!2010.!

! Children!living!in!food!insecure! households!are!more!likely!to! experience!poor!health,!delayed! development,!and!poorer!physical! quality!of!life.12!!These!children!may! also!be!at!higher!risk!for!developing! chronic!health!conditions!such!as! anemia,!asthma,!and!oral!health! problems,!particularly!for!those! children!who!experience!multiple! episodes!of!hunger.!13!!Behavioral! health!issues,!including!anxiety!and! depression!are!also!more!common! among!children!experiencing!food! insecurity.!!Children!experiencing! severe!hunger!have!higher!levels!of! chronic!illness!and!internalizing! behavior!problems.14! ! These!linkages!are!important!given!the! significant!human!and!economic!toll! chronic!diseases!exact.!!Chronic! diseases,!such!as!diabetes,! hypertension,!depression,!and!heart! and!lung!diseases,!affect!nearly!one!in! two!Americans!and!consume!more!than! 80!percent!of!what!we!spend!on!health! care!every!year.15!!Today,!these! illnesses!cause!seven!out!of!ten!deaths! each!year!and!are!the!leading!cause!of!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 11!JS!Lee!&!EA!Frongillo,!Nutritional!and!Health!Consequences!Are!Associated!with!Food!Insecurity!among!U.S.! Elderly!Persons,!J!Nutr!2001;!131(5):1503O509.! 12!PH!Casey,!KL!Szeto,!et!al.,!Child!HealthOrelated!Quality!of!Life!and!Household!Food!Security,!Arch!Ped!Adol!

Med!2005;!15:51O56.! 13!Kirkpatrick,!McIntyre,!&!Potestio,!Child!Hunger!and!LongOterm!Consequences!for!Health,!Arch!Ped!Adol!Med! 2010;!164(8):754O762.! 14!Kirkpatrick,!McIntyre,!&!Potestio,!Child!Hunger!and!LongOterm!Consequences!for!Health,!Arch!Ped!Adol!Med! 2010;!164(8):754O762.! 15!G!Anderson,!Chronic!Care:!Making!the!Case!for!Ongoing!Care,!Robert!Wood!Johnson!Foundation,!2010.!

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disability.16!!Driven!by!the!aging!of!the!population!and!growth!in!obesity!among!risk! factors,!the!prevalence!of!chronic!disease!is!growing:!more!than!half!the!U.S.! population!is!expected!to!have!at!least!one!chronic!condition!by!2020.17! ! Food!insecurity!also!plays!a!significant!role!in!the!management!of!chronic! conditions!and!the!exacerbation!of!complications.!!Given!that!many!chronic! conditions!include!required!dietary!changes!as!a!part!of!recommended!care,!food! insecurity!can!present!significant!challenges!to!health!risk!reduction!and!disease! management.!!! ! For!example,!among!lowOincome!people!diagnosed!with!diabetes,!food!insecurity! has!been!associated!with!a!much!lower!rate!of!glycemic!control.!18!Poor!glycemic! control!is!associated!with!increased!risk!of!heart!attacks,!stroke,!nerve!damage,! blindness,!and!kidney!failure!among!other!serious!complications.19!!Clinical!practice! guidelines!for!many!chronic!conditions!include!recommended!dietary!changes!such! as!reduction!of!sodium!and!fat!intake,!increases!in!consumption!of!fresh!fruits!and! vegetables,!and!avoidance!of!calorieOdense!foods!with!low!nutritional!value.20! Moreover,!medication!regimens!may!require!medications!be!taken!with!food!or! avoidance!of!certain!foods,!such!as!grapefruit,!that!may!affect!certain!medicines.21!! ! Hospital!systems!concerned!about!reducing!readmissions!increasingly!include! evaluation!of!food!security!in!discharge!planning.22!!Other!leaders!are!taking!it!a! step!farther!and!partnering!with!communities!to!address!food!insecurity.!!For! example,!ProMedica,!a!locally!owned,!nonprofit!healthcare!organization!serving! northwest!Ohio!and!southeast!Michigan!started!Come!to!the!Table,!a!program!to! raise!awareness!about!proper!nutrition!and!exercise!and!to!increase!access!to! healthier!food!in!underOserved!areas.23!!In!addressing!readmissions,!ProMedica! discovered!that!food!security!issues!affected!many!of!their!patients!and!presented! challenges!to!following!the!discharge!instructions!that!helped!keep!patients!out!of! the!hospital.!!In!response,!ProMedica!is!implementing!a!process!that!identifies!inO patients!who!are!experiencing!food!security!issues.!The!patient!will!be!referred!to!a! social!worker!or!care!navigator!who!will!further!assess!the!patient!and,!if!deemed! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
16!Institute!of!Medicine,!Living!Well!with!Chronic!Illness:!A!Call!for!Public!Health!Action,!National!Academies!

Press!2012.! !
18HK!Seligman,!EA!Jacobs,!et!al.,!Food!Insecurity!and!Glycemic!Control!among!LowOIncome!Patients!with!Type!2!

Diabetes,!Diabetes!Care!2012;!35(2):233O238.!
19CDC,!2011!National!Diabetes!Fact!Sheet.!Available!online!

http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf,!accessed!March!12,!2013.!
20!See,!e.g,!Dietary!Approaches!to!Stop!Hypertension!(DASH)!NHLBI!(2009).!
21!DG!Bailey,!J!Malcolm,!et!al.!GrapefruitOMedication!Interactions:!Forbidden!Fruit!or!Avoidable!Consequences?!

CMAJ!2013!Mar!5;185(4):!309O316.! 22!S!Kangovi!&!D!Grande,!Hospital!ReadmissionsNot!Just!a!Measure!of!Quality,!JAMA!2011;306(16);!1796O 1797.! 23!ProMedica!Come!to!the!Table!(Fields!of!Green)!program!information!is!available!at! http://www.promedica.org/FieldsofGreen,!accessed!March!7,!2013.!

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appropriate,!prior!to!discharge!the!patient!will!be!provided!an!emergency!supply!of! food!as!well!as!information!about!additional!community!resources.!!! !! Conclusion) ! Without!conscious!consideration!of!hunger,!particularly!in!policy!discussions!about! improving!health!in!America,!we!are!missing!a!critically!important!factor.!!Despite! the!attention!given!to!our!obesity!crisis!and!the!interOrelationship!hunger!and! obesity!share!with!access!to!nutrition!and!common!socioeconomic!demographics,! few!policy!discussions!about!obesity!reference!the!problem!of!hunger.!!Polls!show! that!Americans!are!concerned!about!hunger!and!support!efforts!to!fight!hunger,! even!in!tough!economic!times!and!public!spending!constraints.24! ! Since!food!insecurity!commonly!occurs!with!other!factors!that!adversely!affect! health,!including!lower!socioeconomic!status!and!less!educational!attainment,!more! research!is!needed!to!understand!the!challenges,!interOrelationships,!and!how!best! to!address!them.!!Work!on!understanding!and!addressing!health!disparities!should! also!incorporate!evaluation!of!food!security!status.!!These!efforts!are!needed!to! better!understand!the!extent!of!food!insecurity!among!minority!communities!and!to! design!effective!interventions!that!incorporate!food!security!within!health! promotion!programs.! ! In!the!meantime,!the!coOoccurrence!of!hunger!and!poor!health!status!urges!action! that!requires!strategic!partnerships!to!address.!!Most!vulnerable!are!seniors!and! children,!implicating!significant!policy!issues!and!opportunities!for!policymakers! within!public!health!and!public!insurance!programs,!in!particular.!!Recognition!of! the!links!between!hunger!and!poor!health!are!an!important!first!step!to!promoting! the!important!policy!discussions!and!search!for!understanding!that!needs!to!follow.! !

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24!T!Freeman,!S!Gill,!&!S!Feder,!An!Electorate!Ready!for!Action:!10!Key!Findings!on!Hunger:!Results!and!Analysis!

of!2008!Exit!Polling,!The!Alliance!to!End!Hunger!(2009).!!Available!online! http://www.alliancetoendhunger.org/buildingOpoliticalOwill/hungerOmessageOproject/,!accessed!March!12,! 2013.!

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