Fostering Excellence & Professionalism in Internal Medicine
You Are What You Eat: Food Insecurity and Other Social Determinants of Health Suja Mathew, MD, FACP Governor, Illinois Northern Chair of Medicine, Cook County Health and Hospitals System Department of Health and Human Services Healthy People 2020 Attain high-quality, longer lives free of preventable disease, disability, injury, and
premature death; Achieve health equity, eliminate disparities, and improve the health of all groups; Create social and physical environments that promote good health for all; and Promote quality of life, healthy development, and healthy behaviors across all life stages. 2 Determinants of Health
Policy making Social factors Health services Individual behavior Biology and genetics 3
Policymaking Increased taxes on tabacco sales 1966 Highway Safety Act/ National Traffic and Motor Vehicle Safety Act 4 Social factors Social determinants Physical determinants 5
Health services Lack of availability High cost Lack of insurance coverage Limited language access
6 Individual behavior Diet Physical activity Alcohol, cigarette, and other drug use Hand washing
7 Biology and genetics Age Sex HIV status
Inherited conditions, such as sickle-cell anemia, hemophilia, and cystic fibrosis Carrying the BRCA1 or BRCA2 gene, which increases risk for breast and ovarian cancer Family history of heart disease 8 Healthy People 2020 Health disparities as differences in health outcomes that are closely linked with social, economic, and environmental disadvantage. Health disparities adversely affect groups of people who have
systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. 9 Miss Beebee 57 years old Admitted for evaluation of 3 months of intermittent
abdominal pain and constipation through the ED, high suspicion for colorectal CA DM, HTN, obesity, osteoarthritis, depression No primary care doctor Has seen a cardiologist in the community without hospital privileges Prescriptions are written at walk-in clinics, emergency rooms, and cardiologist
11 Clinically complex patient Multiple chronic conditions Severe primary condition
Concurrent mental and physical health problems Disease affects multiple organ systems Disease causes functional disability Condition requires treatment by multiple providers NQF 2014 12 Hospital course Clinically stable throughout her 3 day admission Colonoscopy revealed a friable mass in the
rectosigmoid BP 182/110 138/82 HgA1c = 14.6; preprandial glucose <150 on weight based insulin regimen Inpatient consults from oncology, GI, colorectal surgery, along with diabetes team 13 Discharge planning To home enalapril and insulin
OTC acetaminophen recommended for knee osteoarthritis Insulin teaching performed by the bedside nurse Low salt diet instruction given by nutrition service Follow-up appointments given with oncology and colorectal surgery and primary care follow-up in the resident clinic 14 Patient did not return to any of her scheduled followup appointments 15
Clinically Complex Patient Sociodemographically Complex Patient Multiple Chronic Conditions Severe Primary Condition (e.g., severe heart Poverty Low income and/or no liquid assets Low levels of formal education, literacy, or health
failure, metastatic cancer, end-stage renal disease) Concurrent mental and physical health problems Disease affects multiple organ systems Disease causes significant functional deficit or disability
Condition requires treatment by multiple providers and/or specialized sites of care literacy Limited English proficiency Minimal or no social support not married, living alone, no help available for essential healthrelated tasks
Poor living conditions homeless, no heat or air conditioning in home or apartment, unsanitary home environment, high risk of crime No community resources social support programs, public transportation, retail outlets NQF 2014 16 Social determinants of health
the structural determinants and conditions in which people are born, grow, live, work and age. Michael Marmot et al., Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health, The Lancet 372, no. 9650 (Nov. 8, 2008):16611669. 17 Heiman, et al. Beyond Health Care: the Role of Social Determinants in Promoting Health Equity
Death attribution in the US in 2000 Low education 245,000 Racial segregation 176,000 Low social support 162,000 Individual-level poverty 133,000 Income inequality 119,000 Area-level poverty 39,000 Galea et al. Am J Public Health. 2011
19 Number of deaths for leading causes of death: Heart disease: 633,842 Cancer: 595,930 Chronic lower respiratory diseases: 155,041 Accidents (unintentional injuries): 146,571 Stroke (cerebrovascular diseases): 140,323 Alzheimers disease: 110,561 Diabetes: 79,535 Influenza and Pneumonia: 57,062
Nephritis, nephrotic syndrome and nephrosis: 49,959 Intentional self-harm (suicide): 44,193 Source: Health, United States, 2016, Table 19(https://w ww.cdc.gov/nchs/data/hus/hus16.pdf#019) (Data are for 2015) How many women die each year from colorectal CA? 21
Death attribution in the US in 2000 Low education 245,000 Racial segregation 176,000 Low social support 162,000 Individual-level poverty 133,000 Income inequality 119,000 Area-level poverty 39,000 Galea et al. Am J Public Health. 2011 22
Heiman, et al. Beyond Health Care: the Role of Social Determinants in Promoting Patient clinical factors Patient sociodemogra phic factors Healthcare entity
structure and quality Treatment/ Process Adapted from National Quality Forum, 2014 Patient outco me
WHO: Final form of the CSDH conceptual framework (Solar & Irwin, 2010) Health Inequities Differences in health opportunities, health status and health outcomes between groups caused by systematic differences in the social conditions that affect health 29 Social Determinants of Health
The economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole. Availability of food Affordable housing Quality education Job security Social connection and safety Living wage Access to transportation Source: Raphael, D. (2009).Social determinants of health: Canadian perspectives. Canadian Scholars Press. Components of Health
Miss BeeBee Returned to the ED 8 months later Cachectic, nauseated Liver metastases Off all medications
32 Heiman, et al. Beyond Health Care: the Role of Social Determinants in Promoting Health Equity Miss BeeBee Discharged to nursing home with plans for palliative and hospice care 34
Let your food be your medicine, and your medicine be your food. Hippocrates (460-370 B.C.) 35 https://www.youtube.com/watch?v=elarP2xX1Y8 36 Food Insecurity vs. hunger Food Insecurity: when consistent access to adequate food is
limited by a lack of money and other resources Hunger: an individual-level physiological condition that may result from food insecurity 37 Slide courtesy of Kathy Chan, Director of Public Policy, CCHHS 38 Impact of food insecurity on health
Forces families to make difficult choices In Cook County, 73% of respondents report purchasing inexpensive, unhealthy food as a coping strategy 62% of respondents chose between paying for food and paying for medicine Associated with adverse health outcomes for children, older adults Source of stress, especially for households with children and older adults
Source: Feeding Americas Hunger in America 2014 report Slide courtesy of Kathy Chan, Director of Public Policy, CCHHS 39 Cook County food insecurity rates with CCHHS locations Prepared by the Greater Chicago Food Depository,
March 2015 40 Why Food As Medicine? New opportunity for patient engagement Strategy to address social determinants
Partnership opportunity Redetermination rates higher for Medicaid + SNAP vs. Medicaid-only cases SNAP eligibility is 165% Federal Poverty Level (FPL) for most households; 200% FPL for households with an older adult (60+ years) and/or a person with a disability Slide courtesy of Kathy Chan, Director of Public Policy, CCHHS 41 Food related chronic disease
Obesity Diabetes Hypertension Heart disease
Stroke Breast CA Colorectal CA 42 Identifying and addressing food insecurity Two-question food insecurity screening administered upon intake, now part of the Health Risk Screening: Over the past 12 months, we worried whether our food would run out before we got money
to buy more. Often true Sometimes true Never true
Over the past 12 months, the food we bought just didnt last and we didnt have money to get more. Often true Sometimes true Never true An answer other than never true to either question puts someone at risk of food insecurity. 43 Identifying and addressing food insecurity (contd)
Patients who screen positive receive: Information about applying for Supplemental Nutrition Assistance Program (SNAP), WIC, and local food pantries in departure summary; Greater Chicago Food Depository Hotline: 773-843-5416 M-F: 8:30am-5pm Counseling from the provider; and A voucher to obtain fresh produce at/near clinic. 44
Progress to date Fresh Truck distribution at 10 sites, with remainder of sites to be trained and scheduled before year end
53 Fresh Truck distributions 5,142 individuals, representing 17,839 household members* 138,350 pounds of fresh produce distributed* 1,126 SNAP referrals with 173 SNAP applications completed* Referrals by Stroger Stroke and Fantus Peds Clinic to community-based Fresh Truck distributions Second year hosting Summer Meals at CCHHS health centers Cooking Matters classes held at Logan Square, Prieto, CORE Center; 17 staff trained in May
*Through June 30, 2017, Slide courtesy of Kathy Chan 46 CCHHS Fresh Markets Weekly markets at Oak Forest, Robbins, and Cottage Grove SNAP users can receive a dollar for dollar match, up to $20/market/week Market operated by Black Oaks
Center Supported by USDA grant that promotes SNAP healthy purchasing 47 Got Food? Smartphone App 48 Free app for Apple and Android devices Designed to assist Cook
County residents locate food resources Developed by James and Phillip Mathew User feedback can be sent to [email protected] 48 Growing partnership between Greater Chicago Food Depository and ACP Illinois Northern Please join us
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