Researchers have published an increasing number of articles about social determinants of health have received over the past decade (Disclaimer: UnitedHealthcare, my employer, has partnered with the American Medical Association to support the inclusion of several new ICD-10 codes to capture these non-medical issues within claims). In 2003, the World Health Organization published the second edition of The Solid Facts, listing 10 factors that are associated with health and life expectancy: the social gradient, stress, early life experience, social exclusion, work, unemployment, social support, addiction, food and transport. In 2018, the Health and Public Policy Committee of the American College of Physicians issued a position paper suggesting the following social determinants of health categories: economic stability, neighborhood and physical environment, education, food, community and social context, and the health care system. The authors go on to state that socioeconomic status (measured by wealth, education and/or occupation), housing, transportation, food, access to technology or the Internet, and racial and ethnic health disparities all affect health.
Earlier this year, Castrucci and Auerbach published a Health Affairs blog post stratified interventions into providing clinical care (downstream), addressing individuals’ social needs (midstream) and improving community conditions (upstream). Addressing individuals’ social needs would include buying food, providing temporary housing and covering transportation needs for high-risk patients. Interventions to improve community conditions encompass actions like the nine interventions developed by CityHealth (earned sick leave, high-quality universal pre-kindergarten, affordable housing/inclusive zoning, complete streets, alcohol sales control, tobacco 21, smoke-free indoor air, food safety and restaurant inspection rating, healthy food procurement) or the 14 interventions recommended by the Centers for Disease Control and Prevention (school-based interventions to increase physical activity, school-based violence prevention, safe routes to school, motorcycle injury prevention, tobacco control interventions, access to clean syringes, pricing strategies for alcohol products, multi-component worksite obesity prevention, early childhood education, clean diesel bus fleets, public transportation, home improvement loans or grants, earned income tax credits and water fluoridation). Castrucci and Auerbach believe work to address individuals’ social needs must continue as efforts are made to improve community conditions through larger policy change.
This post will focus on a single social determinant of health: food (more specifically, food security [i.e., access by all people at all times to enough food for an active, healthy life]). Food security can be viewed as a consequence of multiple factors: lack of adequate education and living wages, lack of access to health care and health information, and exposure to unsafe living conditions such as unsafe water, poor housing, and dangerous neighborhood environments. From a healthcare perspective, food insecurity is associated with the consumption of energy-dense, nutrient-poor cheap food which increases the risk of of metabolic syndrome and diabetes. “Healthy” dietary patterns, more vegetables, fruits and whole grains with fewer red and processed meats, high-fat dairy and refined grains, is associated with a lower risk of diabetes. Lee et al. suggest that a 30% subsidy for either fruits and vegetables alone OR a broader array of healthy foods (whole grains, nuts/seeds, seafood, and plant oils) would be cost-effective at five years among patients within Medicare and Medicaid.
To address food security in the outpatient clinic setting, Patil et al. suggest the SEARCH method. First, screen for food insecurity ( Within the past 12 months we worried whether our food would run out before we got money to buy more, and  Within the past 12 months the food we bought just didn’t last, and we didn’t have money to get more). A response of “often true” or “sometimes true” to either question is a positive screen. Second, educate patients about appropriate coping strategies. Third, adjust medication regimens to account for food insecurity. Fourth, recognize food insecurity by asking about it at every visit. Fifth, connect eligible patients to food banks and supplemental food programs. Patients enrolled in the Department of Agriculture’s Food and Nutrition Service’s Supplemental Nutrition Assistance Program (SNAP) are associated with lower health care spending compared to patients who do not enroll in the program. Finally, help others recognize the relationship between food insecurity and poor health.
Public and private payers may see rapid financial returns by targeting patients with high rates of medical utilization with food delivery programs. Patients receiving Meals on Wheels have been linked with lower healthcare utilization. Berkowitz et al. found that a medically tailored meals program across 17 different tracks over six months was more effective at reducing inpatient admissions and emergency transport than a non-tailored meals program (e.g., Meals on Wheels) when compared to matched controls among patients who were eligible for Medicare and Medicaid. Medically tailored meals were about $200/month less expensive than usual care after accounting for program expenses. The interventions had no effect on home health use.
Can improving community conditions lead to a reduction in healthcare utilization or an improvement in community health? A Cochrane review in late 2018 found limited evidence that food supplementation was not associated with improvements in quality of life, medication adherence or reductions in healthcare spending in low- and middle-income countries. SNAP has been associated with healthier diets and a lower probability of developing obesity. Policy makers should consider how they structure the taxing of unhealthy food and beverages among SNAP recipients to avoid unintended consequences.
Castrucci and Auerbach’s model of downstream, midstream and upstream interventions to address social determinants of health helps frame how likely an intervention will lead to long-term improvement. Medically tailored meals appears to be a cost-effective option for health systems and payors to adopt, but the meals are intended for patients who have already developed a health condition. Our current health system financing structure is unlikely to support upstream interventions given their lower likelihood to immediately impact healthcare costs. Communities and larger groups may be in a better position to advocate for higher levels of food security than individual providers or select payers.