Researchers Get to the Root of Hunger in Primary Care

Around seven years ago during a well visit at Children’s Hospital of Philadelphia, a 12-year-old boy told Saba Khan, MD, an attending physician at CHOP, that there was one problem she could not fix. Intrigued, Dr. Khan asked him to explain further. At first hesitant, the young man finally explained what he meant. He had a pain in his belly that never went away, and he knew exactly what that pain was: Hunger. “I’m always hungry,” he said to Dr. Khan.

Dr. Khan was floored. At the time, she was unfamiliar about how to address the issue of food insecurity because she had not yet encountered it in primary care practice.

“It was shocking and upsetting, and I didn’t have an answer for him,” said Dr. Khan, who is now the medical director of the Healthy Weight Program at CHOP and an assistant professor of Pediatrics at Perelman School of Medicine at the University of Pennsylvania. “I made sure that was the last day I would remain uninformed about what I could possibly do to help him and other children like him.”

Over the next few years, Dr. Khan connected with fellow researchers at CHOP who shared her goal of addressing the sensitive but vital question of hunger in pediatric practice. Since her first encounter with the patient nearly a decade ago, Dr. Khan has seen research regarding food insecurity in healthcare settings begin to flourish.

Defined by the U.S Department of Agriculture as the limited or uncertain availability of nutritious and safe foods, food insecurity (more plainly known as “hunger,” Dr. Khan said) affects 49.1 million people, including 15.8 million children in America. With such a startling number, CHOP has made it a top priority to get to the root of hunger through a number of different initiatives. Along with robust research investigations conducted by PolicyLab at CHOP, Dr. Khan has integrated food insecurity screenings into the Healthy Weight Program, an initiative to advance the prevention and treatment of childhood obesity. She is also gearing up for yet another exciting new initiative to launch in March: a CHOP food pharmacy designed to give children and families access to adequately nutritious food.

Ongoing Research: How Should We Screen for Food Insecurity?

Well before the American Academy of Pediatrics (AAP) announced a policy recommending the universal screening for food insecurity for all children in October of 2015, Dr. Khan said that her colleagues in the department of Biomedical and Health Informatics and PolicyLab were already screening children for food insecurity by embedding a screening tool into EPIC, CHOP’s electronic health record. The screening tool consisted of two questions for families, and a positive response to either question indicated that the family or individual was in a “food-scarce” state.

Since then, the data, which EPIC continues to gather, has helped to inform a number of PolicyLab studies. In initial research that used screening tools during three-year well visits at urban care settings, Dr. Khan and her colleagues discovered that while food insecurity rates in Philadelphia remain at a discouraging 20 to 22 percent range, the researchers were only finding their number at 11 to 13 percent.

“We started to talk about whether it was the way we’re asking about the issue, or is it the people who are asking the issue, or something else,” Dr. Khan said. “That led to other work that was done.”

Danielle L. Cullen, MD, MPH, MSHP, a pediatric emergency medicine fellow at CHOP, began to conduct research into screening for food insecurity in the emergency department (ED). Meanwhile, Deepak Palakshappa, MD, a former PolicyLab faculty member and current assistant professor at Wake Forest School of Medicine, began looking into food insecurity and poverty in suburban primary care practices.

Collectively, the researchers learned even more lessons that could help to shape interventions. First, there is no “one size fits all” modality for food insecurity screening that works for all families – whether it be screening done on paper, face-to-face, or on an Ipad. Thus, providers should be mindful of the way the question was asked, so that families felt comfortable enough to respond truthfully.

“Disclosing that you can’t consistently buy enough food to feed your family is demoralizing, and sometimes families even fear involvement of child protective services,” wrote Drs. Cullen and Palakshappa in a blog post. “We must be aware of these fears, and protect families against perceived repercussions.”

Furthermore, screening shouldn’t just occur in primary care practice alone: Data shows that individual patients may feel more comfortable talking about their hunger in different clinical environments depending on their situation. In fact, a 32.4 percent rate of food insecurity was reported in the ED – much higher than the 2.8 percent of families who screened positive in suburban primary care practices.

The PolicyLab researchers also found that most families nevertheless appreciated the screening. When Dr. Palakshappa and his team asked parents in suburban primary care practices how it felt to be screened for food insecurity, the parents admitted to feelings of shame and helplessness, but some of their frustration was alleviated by discussing food insecurity with a trusted clinician.

Their research also suggests that the solution to helping food-insecure families differs based on geography along with a number of other factors. While urban families had access to government programs providing access to adequate food, suburban families often did not have the same support systems in place.

“Now I think the main ask is what do we do?” Dr. Khan said. “What is the band-aid solution, because we found that we couldn’t do as much for families in the suburban settings.”

Current Initiatives: Going from Hungry to Healthy

In her work with the Healthy Weight Program, Dr. Khan does her best to address food insecurity by making sure that clinicians ask about food access issues at every opportunity. While the link between these conditions and food scarcity may not seem obvious at first, Dr. Khan says it is nonetheless significant: Many children struggling with obesity often do so because they lack access to nutritious food, but they have an excess of junk food.

“All the wrong food excess will lead to obesity,” Dr. Khan said. “Some children start off being underweight but within several years become overweight because they only have access to the wrong food sources and also do not have access to a stable safe place to play or exercise.”

In March, Dr. Khan anticipates the launch of a food pharmacy based at the CHOP Healthy Weight Clinic – a first-time specialty site with contributions from outside donors. Along with providing patients from the Healthy Weight Program and CHOP urban care sites with healthy food, Dr. Khan said the pharmacy may become more of a “pantry” that contains educational resources for families to look into and learn.

“It’s definitely a work-in-progress, but I think that it’s something that’s definitely evolved,” Dr. Khan said. “We have already been giving food out to families, but now we want to attach the screening piece to it and also come up with a dynamic system to see how families benefit from the pharmacy and whether they can give back in its upkeep.”

Dr. Khan expects more information and research studies about the food pharmacy to come out next year, and in the meantime, she looks forward to the many initiatives that have emerged in the last decade.

“All of this work is starting to map out a culture of wellness, and we feel that the pharmacy could really be the epicenter of it,” she said.