Is your patient sick—or hungry?

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Applied Evidence

Is your patient sick—or hungry?

J Fam Pract. 2012 May;61(5):248-253

By

Laura C. Lippman, MD

Helen Lippman, MA

With millions of Americans struggling to recover from job loss and recession, it’s critical to include hunger and poverty in the medical history and physical assessment.

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References

1. Tavernise S, Gebeloff R. New way to tally poor recasts view of poverty. New York Times. November 7, 2011. Available at: http://www.nytimes.com/2011/11/08/us/poverty-gets-new-measure-at-census-bureau.html?_r=2&scp=1&sq=poverty&st=cse. Accessed March 12, 2012.

2. Income poverty and health insurance coverage in the United States: 2010 [press release]. Washington, DC: US Census Bureau; September 13, 2011. Available at: http://www.census.gov/newsroom/releases/archives/income_wealth/cb11-157.html. Accessed March 12, 2012.

3. Short K. The research supplemental poverty measure: 2010. Washington, DC: US Census Bureau; November 2011. Available at: http://www.census.gov/hhes/povmeas/methodology/supplemental/research/Short_ResearchSPM2010.pdf. Accessed March 13, 2012.

4. University Mailman School of Public Health. Death by poverty? June 16, 2011. Available at: http://www.mailman.columbia.edu/academic-departments/epidemiology/research-service/death-poverty. Accessed March 5, 2012.

5. Galea S, Tracy M, Hoggatt KJ, et al. Estimated deaths attributable to social factors in the United States. Am J Public Health. 2011;101:1456-1465

6. Muennig P, Fiscella K, Tancredi D, et al. The relative health burden of selected social and behavioral risk factors in the United States: implications for policy. Am J Public Health. 2010;100:1758-1764.

7. Columbia University Mailman School of Public Health. Poor face greater health burden than smokers or the obese. Available at: http://www.mailman.columbia.edu/academic-departments/health-policy/news-events/poor-face-greater-health-burden-smokers-or-obese. Accessed March 13, 2012.

8. Schwartz K. How trends in the health care system affect low-income adults: identifying access problems and financial burdens. December 21, 2007. Kaiser Family Foundation. Available at: http://www.kff.org/uninsured/7705.cfm. Accessed March 2, 2012.

9. Felland LE, Reschovsky JD. More nonelderly Americans face problems affording prescription drugs. Tracking report no. 22. January 2009. Center for Studying Health System Change. Available at: http://www.hschange.com/CONTENT/1039/. Accessed January 25, 2012.

10. Consumer Reports poll: 48 percent of Americans on meds making risky health care tradeoffs [press release]. Yonkers, NY: Consumer Reports; September 27, 2011. Available at: http://www.prnewswire.com/news-releases/consumer-reports-poll—48-percent-of-americans-on-meds-making-risky-health-care-tradeoffs-130618778.html. Accessed January 3, 2012.

11. A job-loss recovery hurts children most: statistics tell an alarming story [press release] New York, NY: National Center for Children in Poverty; September 15, 2011. Available at: http://www.nccp.org/media/releases/release_135.html. Accessed January 24, 2012.

12. Child Trends Data Bank. Children in poverty. Updated September 2011. Available at: http://www.childtrendsdatabank.org/?q=node/221. Accessed March 13, 2012.

13. Robert Wood Johnson Foundation. Overcoming obstacles to health. Princeton, NJ: RWJF Commission to Build a Healthier America; February 2008. Available at: http://www.rwjf.org/files/research/obstaclestohealth.pdf. Accessed March 22, 2012.

14. Shonkoff JP, Garner AS. Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129:e232-e246.

15. Stein DJ, Scott K, Haro Abad JM, et al. Early childhood adversity and later hypertension: data from the World Mental Health Survey. Ann Clin Psychiatry. 2010;22:19-28.

16. O’Rand AM, Hamil-Luker J. Processes of cumulative adversity: childhood disadvantage and increased risk of heart attack across the life course. J Gerontol B Psychol Sci Soc Sci. 2005;60(spec no 2):117-124.

17. American Psychological Association. Effects of poverty, hunger, and homelessness on children and youth. Available at: http://www.apa.org/pi/families/poverty.aspx. Accessed November 29, 2011.

18. Gottlieb L. Funding healthy society helps cure health care. San Francisco Chronicle. August 23, 2010:A-8.

19. Doane S. High school football team battles malnutrition. December 20, 2011. CBS News. Available at: http://www.cbsnews.com/8301-18563_162-57345857/high-school-football-team-battles-malnutrition/. Accessed March 13, 2012.

20. US Department of Agriculture Economic Research Service. Food security in the United States: key statistics and graphics. Updated September 7, 2011. Available at: http://www.ers.usda.gov/Briefing/FoodSecurity/stats_graphs.htm. Accessed March 1, 2012.

21. Drewnowski A, Damon N. Food choices and diet costs: an economic analysis. J Nutr. 2005;135:900-904.

22. Survey helps doctors help hungry patients [press release]. Portland, Ore: Oregon State University Extension Service; May 27, 2008. Available at: http://extension.oregonstate.edu/news/release/2008/05/survey-helps-doctors-help-hungry-patients. Accessed February 29, 2012.

23. Brcic V, Eberdt C, Kaczorowski J. Development of a tool to identify poverty in a family practice setting: a pilot study. Int J Family Med. 2011;2011:812182.

24. Childhood food insecurity: health impacts, screening and intervention [course summary]. Corvallis, Ore: Oregon State University Extended Campus; 2010. Available at: http://oregonstate.edu/instruct/dce/chi/module5_8.html. Accessed March 13, 2012.

25. Forester RA, Heck RJ. What you can do to help your uninsured patients. Fam Pract Manag. 2009;16:21-24.

26. Byrd C. CVS drug prices takes on Wal-Mart’s generic drug prices—with a gimmicky twist. eDrugSearch. Available at: http://www.edrugsearch.com/edsblog/cvs-takes-on-wal-marts-generic-drug-prices-with-a-gimmicky-twist/. Accessed March 13, 2012.

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Late last year, news outlets nationwide confirmed what many had long suspected: America’s middle class is shrinking. The latest data from the US Census Bureau found that nearly half (48%) of Americans are poor or low income.^1,2

That means 46.2 million people—more than 15% of US citizens—are living below the federal poverty level (FPL), which is $23,050 for a family of 4. Another 97.3 million (about 33%) meet the criterion for low income—earning between $23,050 and $45,869 for a family of 4.^1,2 These numbers are based on the Census Bureau’s new supplemental poverty measure, which considers costs like medical and housing and benefits such as food stamps in calculating poverty.³

The way that census data are analyzed is a key consideration for policy makers and legislators. For primary care physicians, the findings simply serve as a critical reminder that millions of Americans—including some of your patients—are struggling to stay afloat.

In some cases, the problems patients face will be so severe that there won’t be much you can do about them. In others, there are steps you can take to lend a helping hand (TABLE).

TABLE
Help the poor and uninsured: 9 things you can do

Stress the importance of early—and less costly—treatment Use fewer diagnostic tests Do more in-office procedures Request courtesy consults Prescribe generics Reduce polypharmacy Discuss drug costs Use drug samples sparingly (if at all) Connect patients with community resources

Death by poverty?

That’s the title of a summary of a recent study, posted on the Web site of Columbia University’s Mailman School of Public Health.⁴ The researchers found that poverty, low levels of education, and a lack of social support, among other “social” factors, account for as many deaths as heart attack, stroke, and lung cancer.⁵

FAST TRACK

Poverty, low levels of education, and a lack of social support account for as many deaths as heart attack, stroke, and lung cancer.

A related study, also by researchers at Columbia, attempted to quantify the health impact of some leading medical and nonmedical factors. Their findings: The detrimental effects of poverty, smoking, and being a high school dropout exceed those of binge drinking, being overweight or obese, and being uninsured.⁶ The average low-income individual loses 8.2 years of good health simply because of his or her economic status, the lead researcher reported. In contrast, the average loss associated with obesity is 4.2 years and 6.6 years with smoking. The overall health of the US population won’t improve until poverty rates are reduced and educational deficits are addressed, the lead researcher concluded.⁷

That’s not to negate the importance of health coverage, however: A Kaiser Family Foundation study of low-income adults found that fully half (51%) of those who lacked health insurance had not gone to a doctor or clinic in the previous 12 months—and 69% had received no preventive care in the course of the year.⁸

Another survey, completed in 2007, asked adults younger than 65 about their use of medication. About 1 in 7 (13.9%) said they had failed to fill a prescription in the previous year because they couldn’t afford it. Four years earlier, 10.3% had done so.⁹

FAST TRACK

About 1 in 7 respondents said they had failed to fill a prescription in the previous year because they couldn’t afford it.

Recently, however, the situation appears to have gotten even worse. In a 2011 Consumer Reports survey, just under half of adults taking prescription medication reported that they had cut costs by engaging in what the surveyors described as “risky health care tradeoffs”—eg, not filling a prescription, skipping doses, or taking an expired medication.¹⁰

Poverty in childhood has long-lasting effects
Children may be less likely than adults to require prescription drugs, but they are typically the hardest hit by poverty—both in numbers and long-term effects. The poverty rate for those younger than 18 is 22%, according to the National Center for Children in Poverty.¹¹ For kids under the age of 5, it’s more than 25%.¹²

Children of poor, uneducated parents have worse health and die earlier than those whose families are wealthier and better educated, research suggests.^13-16 Even kids from middle class families fall short on measures of health and well-being compared with children whose families are more affluent. What’s more, being poor in early childhood appears to have lasting effects. Regardless of social or economic status or individual behavior later in life, studies suggest that the stress of poverty in the early years is associated with chronic illness and disability in adulthood.^13-16

The bottom line, according to the Robert Wood Johnson Commission to Build a Healthier America: “For the first time in our history, the United States is raising a generation of children who may live sicker, shorter lives than their parents.”¹³ Hunger, or the lack of an adequate supply of nutritious food, is a key factor.¹⁷