Understanding Food Insecurity: Epidemiology, Screening and Intervention

May 5, 2023

Many of us are familiar with the phrase “food insecurity”, but how many of us know how common it is for our patients, or the ways food insecurity is impacting their life and health? And perhaps most importantly, do we know how to have a conversation about access to food and do we know how we can help? Join us in conversation with Dr. Kimberly Montez from Wake Forest University School of Medicine and the Share Our Strength program to learn more food insecurity screening, referral, and resource delivery to families.


Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the kid experts where the complex is our every day. Each week we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change how you care for kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. When we hear the phrase food insecurity, we may have a general idea of what that means, but we don’t necessarily have ideas about all of the ways that food insecurity is impacting our own community, affecting our patients, and most importantly, how we can help. Joining us today is Dr. Kimberly Montez from Wake Forest University’s School of Medicine in Winston-Salem, North Carolina. Dr. Montez will be discussing the Share Our Strength Program and a project to foster collaboration within states and pediatric practices to improve food insecurity, screening, referral and resource delivery to families. Welcome Dr. Montez. It’s great to have you here today.

Dr. Kimberly Montez: Thank you. I’m so excited to be here with you.

Dr. Angela Kade Goepferd: So can you tell us a little bit just about yourself and how food insecurity became a passion of yours and how you got into caring about this particular area of care?

Dr. Kimberly Montez: From a personal perspective, we weren’t screening for it back then, but I probably grew up in a food insecure household myself and I used WIC and SNAP. So I think from personal experience, I’ve experienced it myself. But then I joined faculty at Wake Forest four and a half years ago, and we were already screening in the outpatient clinic that I started working at and had a food pantry and we’re really looking at kind of studying that. And so I joined the group that was studying that. And then the rest is history just became even more passionate about the work from a clinical and research perspective.

Dr. Angela Kade Goepferd: So when we talk about food insecurity and we use that word a lot, what does it mean to be food insecure? How could we define that?

Dr. Kimberly Montez: There are actually probably three terms that are, I think, sometimes used interchangeably. And so maybe we can talk about what those are. We hear the word hunger a lot. I think it’s important to know that each of those categories are different. So hunger is a sort of the physiological sensation that’s associated with a feeling of discomfort, maybe weakness caused by a lack of food. And then that’s coupled with a desire to eat. That’s different from food security, which is a household level economic and social condition defined as consistent access to adequate foods to live an active and healthy life. And this is the definition from the USDA, or United States Department of Agriculture, that is screened annually through an 18 item scale, and it’s used mostly for research purposes.

And then lastly, we’re starting to hear the word nutrition security a little bit more often. And I think that’s sort of the ideal state because food insecurity focuses really on quantity, but nutrition security encompasses the definition of food insecurity, but it really looks more at the quality, so in the nutritional quality of the food that’s being eaten. Families may not consider themselves food insecure if they have enough quantity, but they may not be eating nutritious foods.

Dr. Angela Kade Goepferd: When we talk about food insecurity and or hunger, could you give us a sense of how many families are hungry, how many families experience food insecurity, what are we dealing with?

Dr. Kimberly Montez: The USDA measures household food insecurity annually using that 18 item scale. And so we have results from way back when food insecurity peaked, when the great recession happened, that was around 2008, 2009, about 21% of households with children reported experiencing food insecurity. And then it had been declining over time for households with food insecurity. Most recently in 2022, 12.5% of households with children reported food insecurity. So still a pretty good number.

Dr. Angela Kade Goepferd: And did the COVID pandemic impact those numbers at all?

Dr. Kimberly Montez: Yeah, there was, and we reached one of the lowest levels in 2019 at 13.6% of households with children, that it bumped up to a close to 15% during 2020, The height of the COVID-19 pandemic and then dropped again to 12.5% in 2022, probably because of all of the federal income supports.

Dr. Angela Kade Goepferd: As many of those federal income supports are going away, if families have not yet found access to jobs or secure housing or whatever they need, that number may rise again.

Dr. Kimberly Montez: I think even just this month, the SNAP benefits are going to decrease. And so families who had been expecting larger SNAP benefits will have those dropped and we may see that number rise, once again, to your point.

Dr. Angela Kade Goepferd: Before we talk a little bit more about how we recognize food insecurity in our practice, you’ve mentioned SNAP and WIC a couple of times, and could we just define those for people who may not be familiar with those two programs so they know what is SNAP and who qualifies for that, and the same with WIC?

Dr. Kimberly Montez: So WIC is the special supplemental nutrition program for women, infants and children, otherwise known as WIC. It is a federal grant program that Congress authorizes funding for each year as administered at the state level. To be eligible, you have to be a child under the age of five or a pregnant or lactating individual, less than 185% at all poverty [inaudible 00:05:12]. So for a family of four, that’s $48,470. So that’s WIC. And they provide nutrition counseling, how they provide vouchers for fruits and vegetables, and they provide an electronic benefit transfer for specific food items that they have a list of.

Dr. Angela Kade Goepferd: And this is a federally funded program, so it would be available in all states, is that right?

Dr. Kimberly Montez: That’s correct, yes.

Dr. Angela Kade Goepferd: Okay.

Dr. Kimberly Montez: And then SNAP is the Supplemental Nutrition Assistance Program, formerly known as the food stamps, and it’s similar to WIC in that it provides monthly vouchers via an electronic benefit transfer card to purchase eligible food items. The eligibility is a little bit different from WIC. It’s less than 130% of the federal poverty level or less than 34,000 a year for a family of four.

Dr. Angela Kade Goepferd: And again, federally available program available in all states.

Dr. Kimberly Montez: Correct.

Dr. Angela Kade Goepferd: Let’s swing back to food insecurity and being in the office with families. How might we know that a family is experiencing food insecurity or is there any way for us to tell?

Dr. Kimberly Montez: There are some families that are at higher risk, but I think the main point I want to make is just that you really can’t assume. You can’t make assumptions based on how a person looks or where they live or any of their demographic factors.

Dr. Angela Kade Goepferd: And so I assume that the best way to find out if someone is food insecure would be to screen for food insecurity. So what are some best practices around food insecurity screening?

Dr. Kimberly Montez: The American Academy of Pediatrics, which is one of my professional homes, released a policy statement in 2015 called Promoting Security for All Children. And in that, they recommended universal screening at health maintenance visits or sooner if indicated, using a two question validated screener called the Hunger Vital Sign. So that I would say is one of the best practices.

Dr. Angela Kade Goepferd: And in terms of how we do this screening, is it something that we should be giving out at the front desk? Should we be going over it in the room with the patient? Should the clinic assistant or the medical assistant or the nurse be going over it? Any best practices there in terms of the how?

Dr. Kimberly Montez: There’s more than one way to do it, and I think each practice functions a little bit differently and we’ll have to kind of decide the best workflow that works most efficiently for the practice. There are studies looking at the best way to screen, and I can say that screening from a written perspective, so handing families a paper screener or say an iPad electronically is much more likely to yield a positive rate than by asking verbally.

Dr. Angela Kade Goepferd: And why do you think that is? Do you think people are ashamed to talk about their food insecurity or there’s some stigma attached to that?

Dr. Kimberly Montez: Yes, that is correct. That is what we’re our thinking is that families are less likely to disclose verbally for many reasons, certainly the stigma associated with it, especially if they’re speaking with their doctor. I think another factor is that sometimes the children are in the room with the family and they may not feel comfortable discussing this in front of their children.

Dr. Angela Kade Goepferd: Is there anything that we can say or do to offer reassurance to families if they do disclose food insecurity that we’re here to help them and it’s nothing they need to be embarrassed about?

Dr. Kimberly Montez: I do think there are some best practices giving families the space to talk about it or not. So adding a question that says, “Do you feel comfortable talking about this today with a provider?” And giving them that option to say no. And then also asking, “Do you have an emergency need right now today?” I think are a couple of other screening questions. And then just being cognizant of other children in the room asking if the family wants to talk about it or if they would like to talk about it in a private space, I think are other ways to make families feel more comfortable. Universal screening, so screening everyone and letting families know ahead of time that we are screening everybody for part of their health and that we’re asking all patients.

Dr. Angela Kade Goepferd: Earlier you mentioned that there may be certain populations or demographics that are more likely to struggle with food insecurity, even though we clearly can’t tell just by looking at someone if they struggle with access to food. Could you talk a little bit more about that?

Dr. Kimberly Montez: There are some risk factors just inherent, I think, to poverty, I think is a big one. So families who are experiencing poverty are much more likely to also experience food insecurity. Based on that USDA survey, we are able to get a sense of the families that report higher rates. And so we know that households with younger children, so under the age of six, are much more likely to experience food insecurity. Those who have a single parent or caregiver are headed by women. And we know that black, Hispanic and indigenous families also report higher rates as well as those who are in the southern part of the country.

Dr. Angela Kade Goepferd: It’s interesting that you mentioned that families with kids under the age of six are more likely to experience food insecurity. And it brings to mind for me as someone who has three school-aged children, that many children get school lunch and that they get access to food in schools, which does take one some of the economic burden off of families, but also allows kids to get some food to eat. Could you talk a little bit about the importance of school lunch for food insecure families or for kids who need access to food?

Dr. Kimberly Montez: So the school nutrition programs are the National School Breakfast and the National School Lunch Program. There’s also a summer meal program as well. They provide reduced cost meals for families who are less than 185% of the federal poverty level, and they also provide free meals for those that are less than 130% of the federal poverty level. So they’re great programs. We know that during COVID-19 when children weren’t going to school, there were large disparities and that increased in that food insecurity rates were likely possibly due to the not having access to school meals. So those are a very important source of nutrition for our school-aged kids.

Dr. Angela Kade Goepferd: Here in Minnesota. We recently have been working hard to pass a bill that would allow free school lunch for all kids who attend public schools. Is there any data that you know of or anything to suggest that that has a meaningful impact on food security and on nutrition for kids when they can access free lunch?

Dr. Kimberly Montez: I don’t know that there has been studies on these. Universal school meals, I think, are just starting to get passed. So I don’t know that they have before and after data about kids reporting food insecurity. I can say anecdotally, yes.

Dr. Angela Kade Goepferd: Yes.

Dr. Kimberly Montez: We just know how important school meals are, and they are also associated with a lot of great health outcomes and benefits. So kids are more likely to attend school, they’re more likely to perform better academically if they have access to school meals and are less likely to have overweight or obesity. So we know these school meals aren’t really important.

Dr. Angela Kade Goepferd: And for people who aren’t parents, I have kids who are in school, the way that a school one identifies you as someone who could qualify for free lunch if they don’t have universal free lunch or gets funding for that, is that parents have to essentially fill out a survey to identify themselves. And so again, back to what we were talking about in terms of screening and shame and embarrassment and things like that, there may be a lot of reasons that families even who would qualify for a free or reduced school lunch may not be getting it at school. So from where I sit, just offering school lunch free for everyone eliminates that barrier.

Dr. Kimberly Montez: I agree. It also eliminates a lot of administrative barriers for the schools. I mean, imagine receiving all of those applications and processing them, so I think it’s also a benefit to the school as well.

Dr. Angela Kade Goepferd: Speaking of kind of health outcomes and health disparities, you mentioned that kids who, for example, have access to free school lunch have reduced rates of obesity. The initial logic there is like, “Well, they’re eating more, so how does that work?” But could you talk a little bit about patients who do experience food insecurity, are there health outcomes or health disparities that they may be at risk for versus people who have access to food?

Dr. Kimberly Montez: Food insecurity can really impact individuals at any age. So I know we’re pediatricians and we’re talking about kids, it’s a family unit thinking about the whole entire family. We know that in pregnancy, for example, food insecurity is associated with lower birth rates, higher preterm births and higher maternal stress. In children, there’s an increased risk of chronic conditions like anemia, worsening of asthma, poor nutrition, poor dietary quality, as well as increased utilization of acute care like hospitalizations and the emergency department. So it can really cost a lot of money too to the health system.

Dr. Angela Kade Goepferd: So it’s in our best interest for those of us in healthcare to really do good screening on this because if we can connect kids and families with resources, their health outcomes are going to be better and they’re going to spend hopefully less time in our emergency departments and other acute care settings.

Dr. Kimberly Montez: We know it affects kids physically, mentally, developmentally. And so identifying food security at the earliest possible stage, connecting families with resources can really potentially prevent a lot of these adverse health outcomes that really then go on to potentially affect these kids as adults.

Dr. Angela Kade Goepferd: Can you talk a little bit about the obesity question? I sort of jokingly said earlier that we’re feeding kids free school meals and yet they have less obesity. But I know as a pediatrician that when kids experience food insecurity, they actually are more likely to have higher rates of obesity. And you talked about nutrition quality and access to quality nutrition food, but how can access to food increase a child’s chance of better health outcomes, including lower rates of obesity?

Dr. Kimberly Montez: I think what we do know for sure is that food insecurity is associated with poor dietary quality, malnutrition, poor growth, poor overall health. And we know in adults, at least based on the literature that food insecurity is associated with obesity. But in kids, actually, the studies are conflicting, the association isn’t as strong. Some studies show that it’s not associated, some that it is. But I think what it tracks along with is poverty. So kids who live in poverty are more likely to have overweight and obesity. So we think that it’s mostly the poverty that’s associated with that. Certainly providing income supports through a WIC and through SNAP and school meals and things like that would potentially reduce poverty and thereby potentially reduce or prevent obesity. I think still more research is necessary to make that connection between food insecurity and overweight or obesity, but consistent access is important.

Dr. Angela Kade Goepferd: So in your introduction, I mentioned the Share of Strength Program. Could you talk to us a little bit more about that and what makes that program so successful?

Dr. Kimberly Montez: So Share Our Strength is a national organization. It’s basically a coalition of a private public coalition of advocates really trying to end childhood hunger and poverty in the United States. Share Our Strength has culinary events. They solicit individual donations, they use social media to raise funds, and they really try to find long-term solutions to end hunger. So Share Strength is now working with the American Academy of Pediatrics on a number of initiatives. The goal of the partnership between Share Strength and the AAP is to end childhood hunger by ensuring kids get the food they need. So they’ve done a variety of different projects together. So there’s an Project ECHO, Extension for Community Health Outcomes. So it’s a telementoring program of which I’m one of the faculty members. We meet monthly with community providers of all different types to talk about strategies for screening and intervening clinically. It’s also paired with a quality improvement session.

Dr. Angela Kade Goepferd: You mentioned that Share Our Strength is a national program. Is that available in all states or some states or who might have access to that?

Dr. Kimberly Montez: Yeah, Share Our Strength is a national program, and so they are available basically to anyone everywhere. They also have grant funds available, so if you are looking to fund various projects, they may have funding available. So it’s definitely be on the lookout for that. They are working with the AAP on a community of practice, so practices who maybe aren’t yet screening can join this community of practice and work alongside other practitioners who are working to screen and intervene in clinical settings.

Dr. Angela Kade Goepferd: And if we’re working at a clinic or hospital and aren’t sure the best place to access resources for families who we might be screening as food insecure, would you have any recommendations for people for where they could go to access resources?

Dr. Kimberly Montez: I think identifying a champion in the practices is important, so that person can kind of be the go-to for resources. I would say most communities have a food bank, and so each food bank, especially if they’re through the Feeding America, they have a variety of resources. They usually have a list of pantries that they keep updated. So I would go to the website and start there, potentially set up a meeting with the food bank. They’re always looking to partner with pediatricians and clinical practices. So that might be one of the first places to start.

Dr. Angela Kade Goepferd: And I really like the idea of identifying a champion. There’s so much that we have to keep track of as pediatricians and so many different things that we’re screening for all the time. And I think if there’s someone in the clinic or your hospital system who can really help streamline that for families, and I know here at Children’s Minnesota, we’ve partnered with local organizations to be able to just offer a bag of food to families who screen as food insecure at that appointment so we can do some intervention that day and then connecting them with some of our local food banks and other resources. Well, Dr. Montez, thank you for joining us on Talking Pediatrics. It’s been great to hear from you and learn from you, and we really appreciate you taking time out to be with us today.

Dr. Kimberly Montez: Of course. Thank you so much for having me. One more resource to plug is the AAP FRAC Food Security Toolkit for pediatricians for those practices that aren’t screening. It’s a great guide, goes through step-by-step process. So if you’re not already screening and intervening, check that out.

Dr. Angela Kade Goepferd: Perfect. Thank you so much.

Dr. Kimberly Montez: Thank you.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amie Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.