USPSTF Recommendation: Screening for Food Insecurity
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From the JAMA Network, this is JAMA Clinical Reviews, interviews and ideas about innovations in medicine, science, and clinical practice. Hello, and welcome to our listeners around the world. You're listening to JAMA Clinical Reviews. Thank you for joining us. I'm Dr. Kirsten Bibbins-Domingo, Editor-in-Chief of JAMA and the JAMA Network.

I'm joined today by Dr. Toumani Coker. Dr. Coker is a pediatrician, division head of general pediatrics and professor of pediatrics at the University of Washington School of Medicine and Seattle Children's. Dr. Coker is also a member of the U.S. Preventive Services Task Force.

and is joining us today to discuss the new recommendation statement from the task force on screening for food insecurity. JAMA has published this recommendation statement and the evidence report on which the task force's recommendation is based. Dr. Coker, Toumani, if I may, thank you for joining me today to discuss the work of the task force.

Well, thank you so much, Kirsten, for having me. I'm excited to be able to do this. Wonderful. So I usually begin by just asking if you would summarize, what is the recommendation statement that the task force is releasing today? Yes. Well, this is about food insecurity. Food insecurity is a huge problem in the United States today.

We've got over 10% of households in the U.S. that are food insecure, meaning that their access to nutritious food is either uncertain or limited. And of course, that proportion is going to be much higher when we look at households that have low incomes. And we looked at whether there's enough evidence to know whether screening for food insecurity in the primary care setting leads to direct health outcomes for patients and their families.

And what we found was that there's just not enough studies that have been done that can tell us whether or not that screening in the primary care setting for food insecurity leads to those health outcomes. Now, I know we'll get into this, but I want to be really clear on this. That does not mean that clinicians should not be talking about food insecurity with their patients and their patients' families and addressing food insecurity when it comes to that.

Great. So let's break this down a little bit. So let's start with just the framing that is really the mission for the task force. And that is about screening, whether clinicians in the primary care setting should be asking all patients routinely about food insecurity, common problem associated with poor health outcomes. But the question really for the task force is,

Should clinicians be doing this routinely in their practice for all patients, essentially? And that's the framing for the task force. Is that right?

That's right. And that's our typical framing for screening, for health conditions, for preventive care screening, right? I think food insecurity is quite different because in general, when we look at whether or not clinicians should be universally screening for something in the primary care setting, we then want to link when there is a positive screen

to health outcomes. And I think what we found for food insecurity, which we kind of got into in the viewpoint, is that there may be other reasons for asking about food insecurity that don't necessarily have that link directly to outcomes. And that also impacted the level of evidence that we can find to make a recommendation for or against.

Terrific. So in general, when we look at the portfolio for the task force, there are a lot of recommendations for screening, things that we do routinely across the board. And the goal is to find cases where clinicians might not be aware, patients might not be aware, so that we can intervene in order to have the better outcomes.

So this isn't screening for breast cancer or screening for hypertension. This is about certainly a factor that is related to the risk of poor health outcomes, but a social factor. And talk to me a little bit about why would the task force decide to take this on? Like why? Yeah. Part of the reason is that these social factors are really important part of health. So the social factors are,

As food insecurity is one example, it's related to health outcomes for children, adults, physical and mental health outcomes, quality of life. So it has an impact and a connection to health.

So that is really the driver behind picking up a topic like this. And then I think one of our next steps is how do our methods that are typically focused on some of the examples like cancer screening, how can those be applied for a social determinant of health? Right. So this is different from many of the other types of screening methods.

questions that the task force typically addresses. And what I hear you saying is that understanding the type of evidence, how to frame the question is going to be part of what the task force will really need to be wrestling with. And there is a very nice viewpoint that accompanies this recommendation statement that I would urge our listeners to really pay attention to as well.

I suspect that another reason that the task force took this on is that in some clinical settings, people are doing this routinely, not just clinicians having a heightened awareness or asking if they suspect or intervening if a patient or a family member brings it up, but that there are clinical practices that have adopted this as something to do more universally. Is that correct?

That's right. And we see that in many of our health systems across the country. And that screening for food insecurity may allow that conversation to happen between the provider team and the patient and their family. It can enhance the ability to address other preventive health needs.

So it's not always the necessity of always being linked to a health outcome. There's so many other benefits to addressing food insecurity in the primary care setting that may be unrelated to that leading to a direct health outcome. So, for example, if I want to talk about a preventative care or chronic care management with a patient and they have underlying food insecurity I haven't dealt with.

it's going to be hard for them to engage in that conversation. So that is, I think, part of that reason why in many health systems there is that screening going on already. So when the task force has an eye recommendation, part of the role of the task force is to really tell us the state of the evidence. The way I think about it is that part of the work of the task force is to speak to the research community and to sort of say,

here's where we need more evidence of this type to help us guide evidence-based practice, as well as the task force is also speaking to the clinical community because the clinical community has to keep working even when there is not sufficient evidence. And so tell me a little bit about what type of research the task force thought was lacking and what should the call be to the research communities?

Yeah, so absolutely. Typically, that I statement, right, is a call for more research. So we're talking to researchers, we need more trials, we need more RCTs. I think this one is different. So this is about, do we need more

randomized clinical trials to tell us whether or not we should be screening for food insecurity in the primary care setting. That's a question because it's not necessarily that we need more trials. I think we have to go back and look at the question that we're asking. Do we want evidence that screening

for food insecurity in the primary care setting directly leads to those health outcomes? Or are there other pieces that we can think about that that screening can lead to? So again, I talked about maybe I really want to deal with chronic disease management around diabetes for a patient, but they can't do any of the things that we're talking about unless we deal with the food insecurity.

So that is very different than our typical process of screening leads to a positive screen, leads to a primary care intervention or referable intervention, leads to health outcomes. So I think what we found and what we outlined in that viewpoint is we need to really think about how these social drivers work.

may have a really kind of a different process and different reasons for screening. That's one of the pieces that's just different about food insecurity and probably is going to be different about any other social drivers of health topics that we want to tackle. So it sounds like it is not just the design of a study that might need to be

contemplated when we were thinking about the new research that needs to happen. It is also understanding what are the multiple of types of benefits in the clinical setting that might accrue from understanding more about a patient's food insecurity. That's exactly right. And I think the other piece that

that we kind of go through in the viewpoint and that makes this a different kind of I statement is that we realize that food insecurity, the interventions that we can either provide in the primary care setting or even referable from primary care, it's only a small sliver of what needs to happen to address really food insecurity in that patient and their family. Because food insecurity is

And the foundation of it is about poverty. It's income focused. Right. And so there are structural reasons why families are in poverty or don't have enough income to be able to provide the nutritious food that they need.

And those are going to be greater for certain populations, too. So we look at veterans, older adults, families with young children, folks with disabilities. All those folks have different reasons for having lower incomes. And primary care is one piece of the puzzle and probably not even the biggest piece of the puzzle.

So it's because the intervention, once you have screened positive, the intervention certainly lives in general outside of the primary care setting for the most part, even if health systems have ways to provide access to food in general, the referrals are outside. And then the larger policy landscape that is related to poverty and to access to nutritious foods certainly would have an effect in this particular area. So what is the recommendation to clinicians?

Even when there's not an official recommendation on what to do, what type of guidance would you give clinicians in this area? Yeah, the guidance to clinicians is critical.

have these conversations with your patients and their families, identify food insecurity when it occurs, and be able to know the resources that you can send folks to address food insecurity. As you said, Kirsten, those interventions are typically going to be outside of primary care. So clinicians...

have and will continue to need to know the resources in their communities, the food banks, being able to connect families. I'm a pediatrician, so I talk with families with young children, with infants. We make sure that they have WIC and

So really being able to know those resources and have that connection to address food insecurity when it takes place. Because with the numbers of households that are food insecure, every primary care clinician, you're going to see a family, a patient that is experiencing food insecurity at some point. And so we've got to be able to meet their need.

So I want to give you the last word on what the main message is of this recommendation that you'd like our listeners to take away. Thank you. So food insecurity, it's a big problem in the U.S. And as a topic that we looked for evidence of,

of whether screening in the primary care setting leads to health outcomes. There are just not enough studies to make a recommendation for or against. And it's really important that clinicians are able to have the conversations about food insecurity with their patients because it's really part of that relationship that we're building in primary care. And I think it allows us to really be able to meet families and patients where they are.

Wonderful. Thank you very much. I'm Dr. Kirsten Bibbins-Domingo, and I have been speaking with Dr. Tumani Coker. We've been speaking about the new recommendation statement from the U.S. Preventive Services Task Force on screening for food insecurity. You can find a link to the recommendation statement, to the evidence report, and to the viewpoint from authors from the U.S. Preventive Services Task Force about this topic. Those links are available in the episode's description.

This episode was produced by Daniel Musisi at the JAMA Network. To follow this and other JAMA Network podcasts, please visit us online at jamanetworkaudio.com or search for JAMA Network wherever you get your podcasts. Thank you for listening. This content is protected by copyright by the American Medical Association with all rights reserved, including those for text and data mining, AI training, and similar technologies.