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Food Insecurity in Older Adults: Podcast with Hilary Seligman

In this week’s podcast we talk about food insecurity in older adults with UCSF’s Hilary Seligman, MD. Hilary has done pioneering work in this area. Some of this work was funded by Archstone Foundation (full disclosure: Archstone is a GeriPal funder).

Hilary's expertise runs the gamut from federal nutrition programs (including SNAP), food banking and the charitable feeding network, hunger policy, food affordability and access, and income-related drivers of food choice.

I have a confession.  I knew almost nothing about food insecurity before this podcast.  Is it hunger? Why should we think about food insecurity and health in the same sentence? Why is this an issue for older adults in particular?

I was absolutely blown away by what I learned in this podcast. I have since quoted Hilary Seligman 4 or 5 times in other meetings.

Food insecurity is one of those topics that people don’t talk about but is likely far more critical to the health and well-being of the people we care about than other topics we spends gobs of time and money on (e.g. cholinesterase inhibitors for dementia).

So take a listen and if you want to take a deeper dive in some of the topics we talked about, here are the links:




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Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, in our studio we have a very special guest

Alex: A very special guest, Hilary Seligman, who is a clinician researcher, associate professor of medicine and studies food insecurity. Welcome to the GeriPal podcast, Hilary.

Hilary: Thank you. Thanks for having me.

Eric: I am so excited to learn a lot about this topic because I don't know a lot about this topic, but before we do, do you have a song request for Alex?

Hilary: I have a song request for Alex. It's "Where Do the Children Play?" by Cat Stevens.

Alex: This is a terrific song. (singing)

Alex: Usually my vocals gets stretched like in the last Hotel California with really high songs. This song really gets the lower end of the vocal register.

Eric: What's your history with the song, Alex?

Alex: I played this one for Earth Day in high school. It was like one of the first Earth Days, you know, when they just started Earth Day and played with a band in front of the whole high school. It went great, except that at one point I was supposed to signal to our drummer, Rodrigo, to do this chime thing and I forgot to do it. And afterwards, the bandmates were like, "Dude, you forgot to signal."

Eric: I blame it on Rodrigo. He should have known.

Alex: The drummer, yes.

Eric: Percussionist.

Alex: Yes.

Eric: That's their job. They got one job. You just had to do it. Like why was it your responsibility, Alex?

Alex: It should have been me [laughing].

Eric: So Hilary, can I ask a really stupid question to begin with?

Hilary: Go for it.

Eric: What is food insecurity?

Hilary: Yeah, I knew that was coming. The USDA defines food insecurity as the lack of access to enough food for an active, healthy life, which doesn't exactly get to the way we conceptualize it in the U.S. IN the U.S., it's a lot, at least in the way we measure it, about lack of money or other financial resources for food. But there's a lot of other things in life that makes it difficult to access food and these tend to occur with food insecurity, so we think about them often in the same bucket. These are things like, my dentures don't work well so it's challenging for me to eat. It's difficult for me to get to the grocery store. I don't have the capacity to prepare a meal from raw ingredients. All of these things, often, particularly in older adults, tend to occur together and so we often treat them in one big bucket.

Alex: And my question is, this is obviously has face validity as a serious problem, right? Food insecurity. Is this something that, you know, most of our audience are clinicians, right? Doctors, nurses, some social workers. Is this something that belongs in the clinical sphere? Is this a health issue?

Hilary: Yeah. We are just now starting to understand the profound clinical implications that food insecurity has. And one of the ways we think about it is all of the mechanisms through which food insecurity has an impact on your health.

Hilary: The first place people always go is in the quality and the quantity of the food you eat because we know when your food budget gets shrunk to very, very, very little, people compensate by changing the amount of food they eat, they eat less obviously. But they also concentrate their dietary intake on foods that are very inexpensive, which tend to be very low in nutrients, very high in energy. So these are foods that you would think of as being likely to lead to obesity or diabetes or high blood pressure because processed foods tend to be high in salt.

Hilary: All of that is true and so we know that food insecurity is linked with health outcomes that way, but there are also a number of other ways, and I'll mention two of the most important ways. One is that food insecurity is such a ... Or food is such a basic need that when people don't know where their next meal is going to come from, their cognitive bandwidth becomes focused on where they're going to get that meal and it crowds out all kinds of other things that in many cases are health related. Am I going to check my blood sugar? Am I going to refill my medication? Et cetera. There are also competing demands, do I have money for both food and my copayment? Do I have money for both food and my medication refills?

Hilary: And then the final one that I will mention that's extremely important is we know that food insecurity and poor health are really tightly linked in the U.S., And part of it is because food insecurity causes poor health. But we also know that being in poor health in the U.S. is really expensive. Both because there's out of pocket expenditures, but also because once you're ill or frail, it makes it much more challenging to hold down a job. And so we also know that poor health puts you at increased risk of food insecurity

Eric: And these studies looking at outcomes and food insecurity, sorry for my daftness, but when we're thinking about how they're defining food insecurity, is it both access to food and access to healthy food? How am I supposed to conceptualize that?

Hilary: The measure that we use both for research and for clinical purposes is really asking people about running out of money for food.

Eric: Okay.

Hilary: However, we know that when you have all of these other risk factors, you're also at high risk for food insecurity. And we know older adults are at really high risk of food insecurity as well. Overall, about 1 in 11 people in the U.S. live in a food insecure household, and older adults are at just as high risk as the general population. And in some cases, at even higher risk for the reasons that I just mentioned.

Alex: And I want to differentiate, if you could, could you say a little bit more about how food insecurity differs from hunger? And I'm just thinking, certainly in research circles, food insecurity is a thing. But for lay audience or clinicians who might be new to this concept, how do they think of it as different from hunger, which they've certainly heard of?

Hilary: Such a great question. And particularly important for understanding why we talk about hunger or food insecurity and health in the same sentence.

Hilary: Hunger is defined as that physical sensation you get when you don't have access to food or when your lunch is late or you are dieting or something we've all experienced food insecurity differs because it includes both that physical sensation of hunger and all of the coping strategies that you use when you anticipate that you're not going to have enough money for food. And the reason that's so important is that most of the health outcomes that we're talking about with food insecurity are not related to the hunger in and of themselves, they're related to those coping strategies. And that's why in research circles and increasingly in clinical circles, we really are focusing our attention on food insecurity, even though it really blunts the emotional response that people have to that word hunger. And if we more often said to ourselves and really tried to process the fact that 1 in 9 Americans, 1 in 9 older adults live in a household in the U.S. that's at risk of going hungry, I think we would have a much more communal response to that, that would activate a lot more efforts to reduce food insecurity in the U.S.

Alex: So at risk of going hungry is a way to sort of draw that ... Because you're absolutely right, like food insecurity doesn't have an emotional valence to most people.

Hilary: That's right.

Alex: Whereas hunger is a powerful emotional resonance with people. So if you can tie it together, I like the way that you said this, 1 in 9 older adults is at risk of being hungry because they have food insecurity.

Hilary: Yeah. So if you think about it, if you had $5 a day to spend on food, which is about what somebody receiving SNAP benefits or Supplemental Nutrition Assistance benefits might have in their benefits, $5 a day to spend on food, you would have to decide how to spend that $5. And you could either buy a menu of healthy food options, which probably would not bring you enough calories to not feel hungry. Or you could elect to buy very energy dense foods and you wouldn't go hungry. But those tradeoffs that you've made, the fact that you have ... Instead of having oatmeal with berries on top for breakfast, you elected to have a doughnut because it was going to fill you up longer. It has a lot of fat in it, it has more sugar in it.

Hilary: Those coping strategies have some longterm implications that are going to be important clinically if they're sustained for years or decades. And we know that the typical pattern of food insecurity in the U.S. isn't a very short term experience, but it's something that people have been coping with for many, many, many years. And over those years, the cumulative effect of coping with food insecurity year after year after year does have adverse implications for your health.

Alex: I wonder if we could, and we should get back to the SNAP program, the Supplemental Nutritional Assistance Program. Did I say that right?

Hilary: Yep.

Alex: Yes. In what can we do about it? But first I wonder if we could talk more about ... So we've established the linkage between food insecurity and health. Can we talk more about what clinicians might do? What clinicians ask about this in everyday practice or is it only if you have certain triggers and then how, what they ask? Maybe the first is what they ask.

Hilary: Older adults are at really high risk of food insecurity and they tend to have a lot of the illnesses that we see as red flags that trigger us to want to screen.

Hilary: We know that clinicians are very, very poor at being able to identify which of their patients are likely to be food insecure. So when you are talking about an older adult or a chronically ill or a frail population, the recommendations from experts, not grounded in particular evidence, would be to screen everybody. There are some predictive algorithms that have been created for older adults in particular that try to use administrative data to figure out who in the population is most likely to be food insecure. And there are things that you would imagine, people who are enrolled in both Medicare and Medicaid, for example. And there are other risk factors like having multiple comorbidities that make you at really high risk of food insecurity.

Hilary: But for most people we say, the only way to really find out is to ask. And in the clinical setting we ask using a two item screen called the Hunger Vital Sign. You can just Google Hunger Vital Sign, and it asks patients, is it often sometimes or never true that you had to worry about access to food before the end of the month? And is it true that you didn't have access to healthy foods?

Alex: And both of those are often ... What was it?

Hilary: Often, sometimes, or never true.

Alex: Okay, got it. So two-item screening question. And the first question is about, do you sometimes worry that you won't have enough food at the end of the month? And the second question was ...

Hilary: Do you sometimes run out of food?

Alex: Do you sometimes run out of food? And how do you score that?

Hilary: If you respond that you are sometimes or often experiencing this, sometimes or often response to either of those two questions, we consider you food insecure. And the reason is that the downside of inappropriately "diagnosing" somebody with food insecurity is really low because really what you're trying to do is you're trying to identify those people that have a social need, and that need is an an emergent or urgent need for support with food. Because those are the people for whom you want to invest the time clinically to try to connect them with food resources, either in the community or federal food resources.

Eric: In a medical practice, who's responsibility is this? A, to screen and to do anything about it. Like in med school, I was never really taught anything about what to do about food insecurity. I was taught about weight loss, diagnosis, trying to work it up, get your thyroid levels checked, all those other things. But what am I supposed to do as a practitioner if they screen positive?

Hilary: Great question.

Eric: Or do I just send them to the social worker, if there is one?

Hilary: First of all, we've had a lot of experience with different people in the practice doing the food insecurity screening. Your question is really, should the physician or the nurse practitioner be doing that clinical screening? And it turns out that people are more comfortable and more willing to reveal their food insecurity when it's not the physician who does the screening. And the further away it is for the physician, the more likely people are to reveal it. So more likely with the nurse, even more likely with the nurse's assistant and maybe even most likely with the front desk staff that's checking you in.

Eric: Really?

Hilary: So what we say is absolutely no need for the clinician to do the screening, but a really important need for the clinician to follow up on a positive result.

Alex: But why do you think that is, that the further away they are from the clinician, the more comfortable they are asking this question?

Hilary: I think it's the power differential that enters the room. Even among those clinicians who are most good at building rapport, there is always a bit of a white coat effect in the room, whether we want it or not. And the farther we can get away from that.

Hilary: Food insecurity historically has been viewed as very stigmatizing. And there's been a lot of work to ask patients, do you want people to talk to you about this in the clinical setting or do you feel stigmatized by it? And invariably patients say, "I am glad my provider knows about it. I am glad we talked about it." And clinicians say, "I understand something about this patient that I didn't understand before that is important for our clinical encounter."

Hilary: Good research has shown that it's not stigmatizing to discuss it, and it's not stigmatizing and can even be helpful for that discussion to happen by the clinician. But the screening process itself still makes patients often feel very uncomfortable.

Alex: That's interesting. So let's say that a patient comes, geriatrics clinic, a patient comes in, front desk, they screen this patient, they screen positive, they let the clinician know. How ought the clinician enter into the conversation with the patient about this?

Hilary: There's a number of ways to enter it, depending on what's on the table for your conversation today. So there's a couple of different responses that people can have. One is around medication non-adherence and picking up prescription refills. One way to enter this conversation is to talk about what kind of choices patients are making when deciding whether to put down a copayment for a medication refill or even in deciding whether or not to show up for a followup appointment. So that's one way to enter the conversation.

Hilary: The second way to enter the conversation is around diets. So many of us with longterm relationships with patients have had conversations about what you eat and when you understand that a patient is food insecure, it has a complete different balance to those conversations because what you might recognize is, well, you know, all my attempts to ask this patient to transition from white rice to brown rice, why is that so difficult? It's one little thing, or to step away from tortilla chips and replace them with some vegetables. Why is this so difficult?

Hilary: When you put that in the context of this being an economic strain on a very limited food budget, and I ask people to always go back to thinking to yourself, it may be $5 a day that people have to spend on food. Then you can start reaching your patient in a new way because then we understand some of the really tremendous impacts that these requests for dietary changes might be having on the household food budget. And we may actually have to step away from some of those dietary recommendations because they can feel disempowering and frustrating for people who don't have the financial capacity to do them and instead focus on things like portion sizes.

Eric: Yeah, and I can imagine as a physician, it's really hard to grapple around this idea of $5 a day as your overall budget. It just reminds me how privileged of a place I come in. Like, how would I even do $5 a day?

Hilary: It's a great question, and I don't want to interrupt you, but I will say that there is a week of the year that is often spent doing a SNAP challenge, where people volunteer in order to understand the experiences of food insecure people to spend $5 a day. Now, you probably are used to spending $5 a day just at Starbucks. It is hard. It is really hard and it's particularly hard when you're in a one-person household, which is the experience of many older adults because there are very few economies of scale.

Hilary: One of the things you will quickly notice is not only how hard it is, but how crappy you feel when you eat that diet. It is a lot of processed foods. It is a lot of high calorie, high sugar foods. And one of the other things that you will notice, it is perfectly doable to eat a healthy diet on $5 a day if you are able to expend a lot of time and physical energy. And time and physical energy are two things that are also in extraordinary short supply among all adults in the U.S.

Eric: So how does time and energy ... How to get healthy meals?

Hilary: Because raw ingredients are much cheaper. And so the more you're able to do that processing yourself, the more you're fine with buying the whole chicken instead of the chicken parts. The more you're able to make your own, you know, soak your own oatmeal overnight, soak your own beans overnight. The more you can do all of that, the cheaper your meals become.

Eric: You can get it in bulk.

Hilary: But it takes a lot more energy, a lot more planning, and a lot more bandwidth to do that. And again, cognitive bandwidth is not something that a food insecure household has a lot of leftover because there's a lot of energy being put into other things.

Alex: I like this idea of the SNAP challenge. Do you know approximately what time of year? Okay, we'll look that up. We'll put a link to it in the post associated with this podcast on our GeriPal website.

Alex: I wanted to turn, if we could to, okay, so the clinician is entering into a discussion, perhaps around medications, choices they're making, noticing they're not getting refills, around this issue of food insecurity. What can clinicians do to help patients who are food insecure?

Hilary: The best thing for a food insecure patient is to connect, connect them with SNAP, and there is really high rates of people eligible for snap who are not enrolled in the older adult population.

Eric: Can you give me a one liner what SNAP is?

Hilary: Yeah. SNAP is the Supplemental Nutrition Assistance Program. It is a federal nutrition program that used to be called The Food Stamps Program, so you can think of it as food stamps, but the name was changed primarily because the "food stamps" word carried so much stigma with it. It is not now delivered through actual food vouchers or food stamps, it is an electronic benefits card that looks much like a Visa or MasterCard, that you can use at the grocery store for any non-prepared food ingredients.

Eric: And who's eligible for SNAP?

Hilary: The eligibility criteria vary from state to state, but in general, people who are citizens of the United States and whose incomes are below 130% of the federal poverty line after certain deductions are eligible.

Hilary: Now, it's key in the older adult population to realize that the medical expenses that can be deducted from your income, the list of acceptable medical deductions is very, very, very long. And so older adults with incomes that are higher than 130% of the federal poverty line are often eligible for SNAP benefits as well.

Alex: Let's say a patient is eligible, what is the process of helping that patient obtain ... Well, how do they find out? Do we refer them to a social worker? What is the process of getting your patient enrolled in SNAP?

Hilary: SNAP benefits are administered at the level of the state. So exact criteria and the exact processes are different for every state. Here, going online as your friend. In many states, you can initiate the process online, which is great if you have the capacity to support that work in the clinical setting, particularly because we are often much more savvy with computers than our patients are. In some states, the entire application can be completed online or by phone, including the actual signature of the application. And then the benefits card arrives in the mail.

Alex: Great.

Eric: And it sounds like SNAP is helpful for those people, maybe gives them a little bit of supplemental to pay for some of this food. For a lot of our older adults' access, they just maybe can't get to the grocery. Are there things that we can do for those individuals?

Hilary: Yeah. We think of four buckets of the way that a food insecure person gets food, and the first two are things that we don't tend to think about as clinicians at all, but they're the most important for our patients, and that is moving food around in your food budget. For example, I'm not going to check my blood sugar this month because I can't afford more strips, I'm going to buy food instead and relying on family and friends or your informal support network, which sometimes is a very longterm coping strategy for people.

Hilary: When those two coping strategies have been exhausted, then people tend to have to move outward into the community and there's two buckets then. One is the federal nutrition programs, and SNAP is the most salient for older adults. But also the food that comes, for example, through the the adult food program that provides food for congregate meals comes through the federal nutrition programs, also paid for through the Farm Bill, just like SNAP and other federal nutrition programs like that.

Hilary: And then the fourth bucket is the charitable food system, and the charitable food system includes home delivered meals and medically tailored meals and other food banks and food pantries that for somebody who is physically able to pick up groceries and bring them home, can be accessed as well.

Eric: And the home delivered meals, those are like meals on wheels?

Hilary: Exactly.

Alex: So we've got clinicians who may be able to refer to SNAP, maybe able to explore with their patients about the difficult choices they're making. This $5 a day in supplemental resources, it just seems like so little. What are you advocating for as far as policy change at this time? Is SNAP threatened ought the amount of supplemental nutrition assistance be higher than $5? Are there other things that we could be doing from a policy and programmatic perspective?

Hilary: So many good questions in there. First of all, $5 a day isn't a lot, but it can go a really long way in a household that is food insecure. And that $5 a day may actually double people's food budget or may triple their food budget that they currently have available. And we know from a lot of good academic work and from a lot of talking to patients in clinical settings that existing SNAP benefits are not adequate, and there is excess food need that's very clear. A person enrolled in SNAP, however, has a 20% to 30% lower likelihood of being food insecure than a similar person not enrolled in SNAP.

Hilary: Another way of saying that is SNAP reduces a food insecurity by about 20% to 30%, which is tremendous. It is actually considered one of the two most important antipoverty programs in the United States in terms of scope and scale.

Hilary: SNAP, the first and the other is the earned income tax credit, which is not generally helping older adult households because they're not earning income. And so SNAP is really the most effective poverty alleviation program that we have in the U.S.

Hilary: Your next question is about what policies are on the table. Well, there are a number of policies that are being debated right now at the federal level. All of which would reduce benefit levels and reduce the number of people who are eligible for SNAP benefits. At the same time, there are state efforts to try to do the opposite, in some cases, and some of these are particularly relevant for older adults. For example, there are efforts to make the SNAP application more streamlined in some settings for older adults. And that can have a really profound impact on the number of people who are able to enroll and perhaps more importantly the number of people who are able to stay enrolled.

Hilary: One of the things that we know about these households is income levels aren't likely to change. They don't change very often. And so the need to prove that your income hasn't changed every 6 or 12 months or else be kicked off of SNAP is absurd. And so efforts for this population to, for example, say, show us your income once and we're going to trust that that's likely to stay the same for the next three years or four years can be really effective at maintaining benefits for older adult households.

Alex: It's interesting that there's this tension on this policy point here between what's happening at the federal level and what's happening at the state level. SNAP is a federal program, right? But the eligibility and the application process are decided by the states? Do the states contribute at all? Is it like Medicaid, where there's a federal portion and a state portion?

Hilary: Yeah, SNAP is an entitlement program. So if you meet basic eligibility criteria, you are entitled as a citizen of the United States to SNAP benefits, which makes it very unique among many of our social programs.

Hilary: The federal government pays for the dollar value of the SNAP benefit plus half of the administrative costs. So what the state puts in is relatively low, and that means that states have enormous economic incentive to help people enroll if they're eligible in the program. In addition, and this is very underappreciated but very important, every dollar in SNAP benefits is assumed to have a $1.90 of direct economic activity in the community because that dollar is spent immediately. It has to be spent within a month, generally. It's spent locally and it's spent on food, which has a whole production chain behind it and a whole host of people who have contributed to the production and processing and delivery and transportation of that food. And so it is of economic benefit to the states to help people maintain their enrollment.

Hilary: But SNAP is by far the largest portion of the Farm Bill. And so any efforts to reduce our spending on the Farm Bill get very quickly pushed up against the desire to kick people off of the SNAP roles.

Eric: And outside of SNAP, are there other things that cities or states are doing that you think are really interesting or novel to help with this issue around food insecurity, especially if it's around older adults?

Hilary: Yeah, a lot of local communities have responded to the inadequate benefit levels in SNAP and the fact that a lot of people who are food insecure are not eligible for SNAP by creating their own local voucher programs. We run one ourselves in San Francisco called EatSF, called in other places, Vouchers For Veggies. And essentially this allows local funding to help meet what we call the SNAP gap, what's left over after you get all your SNAP benefits and you still don't have enough money for food. And in many cases, those vouchers are good only for specific healthy foods like fruits and vegetables.

Hilary: I don't want to forget here as well that there are a lot of people who just aren't eligible for SNAP and they still are food insecure, and this is important for that population too; people who are undocumented, people whose incomes are just above that eligibility threshold and other populations that ... Noncitizens who are documented. There are a number of other populations who are really struggling to make ends meet to get food on the table and yet there aren't federal nutrition program options.

Alex: That's great. Okay, I have two more questions. My first one is for Eric.

Eric: Yes.

Alex: You are the fellowship director for the Geriatrics Fellowship here at UCSF.

Eric: Yes.

Alex: Do you teach food insecurity in your geriatrics fellowship?

Eric: No, we do not. And I think this is the classic issue around what we focus on. We focus a lot on weight loss in older adults and also incorporate to that is access to food. So a fair amount is focused on that, but not a lot specifically around outside of that on food insecurity. Actually, there's a little bit of it, but it's not specifically-

Alex: So you don't teach your fellows to screen for food insecurity or learn about SNAP or options or impact it might have when their taking medications, difficult choices they're making?

Eric: There maybe individuals in our fellowship-

Alex: I love putting Eric in the hot seat.

Hilary: Older adults with weight loss, there are so many reasons, obviously for older adults to be losing weight, but older adults with weight loss, absolutely need to be screened for food insecurity. Although there are many, many things, again, that can be coexisting that are important in that weight loss, lack of money for food is very well documented as a significant complicating factor in weight loss.

Alex: But I suspect this is the situation around the United States that most geriatrics fellowship programs are not educating fellows about this important domain. It is relatively newly recognized on the scene. What do you have to say to these geriatric fellowship directors to get them to include it in their curriculum?

Hilary: Well, let me say two things about this. One is that food insecurity has traditionally been more of the domain of public health and of healthcare, and that's why you get this tension. And yet we know now that the clinical sequelae of food insecurity are broad enough and deep enough that if we aren't asking about food insecurity, we are missing a really important contributor to health outcomes that we are often sort of beating our heads against the wall. Like, what is going on here? How am I able to help? How am I able to make the situation better?

Hilary: So it is often gratifying for both the patient and clinician to have the opportunity to realize that, oh, I understand what's going on here. That would be if this were a needle in a haystack and not 1 in 11 people in the U.S., then we would say, you know, we're not missing that many people, but there are an extraordinary number of people in the U.S. for whom this is relevant.

Eric: We had a podcast on the social determinants of health and one of the questions was, at what point is it like the healthcare system's responsibility for some of these social determinants and at what point are we just feeding into this medical industrial complex that just wants to take over all aspects of life and then make a profit over it?

Eric: So when we think about food insecurity, how important is it for healthcare systems to think about it? Because I believe you, it sounds like it influences outcomes versus saying, you know, it's important and it's important that others deal with it. Where do you fall on that?

Hilary: This is such an important question and I would say it's the most important question that people in the social determinants of health world are wrestling with. And here is where I come down is that, we don't in 2020 have the luxury of saying that's not our problem because our patients are dealing with the consequences of their social needs every day. And they're having significant impacts on their clinical trajectory. And I think if healthcare is only helping those social needs and not helping those structural problems or those policies that create those social determinants of health. We are always going to be on, you know, like the rat running in the wheel because we can't address these problems. Only by addressing these social needs in the minute, during a clinical visit, we will become overwhelmed with needs. And so ultimately we have to be better advocates for policies and structures that better address the social determinants of health so that we don't have to address them in the clinic where it isn't time efficient and it isn't cost efficient.

Alex: Did you want to say something here about the difference between social determinants and social needs?

Hilary: Yeah, the social determinants are those structures and those systems and those processes that predispose people to adverse health outcomes where they live and work and play. Just because you are experiencing some or all of those systems or structures that predispose you to adverse health, doesn't mean you necessarily have a social need today. And the people who we really want to prioritize for accessing the charitable food system or accessing SNAP benefits are those people who have a social need today, those people who not only tell you that they're food insecure, that over the last 12 months they've worried where their next meal was going to come from, but those people who are saying, not only is that true for me in the last 12 months, but actually today I'm worried that I'm not going to have enough money to get me to the end of the week. Those are the people who have an acute social need and that's where clinical care and clinical settings have to be at the table. Because if we're not, we are allowing our patients to develop acute complexity of their diseases that they don't otherwise need to be exposed.

Eric: Yeah, I mean I always think back to like the heart failure patient, they come to the hospital, they're getting three meals a day, we're giving them low salt, some healthy, tasteless meals, and then we tune up their heart failure regimen perfectly to this inpatient, low salt diet, and we don't even acknowledge kind of what they're going back to...

Hilary: That's right. Well, let me give you a good example of this. We did a study where we looked at the rate of hospital admissions for hypoglycemia in every day of the month. Why on earth would your rates of admissions for low blood sugar be any different on the first of the month, the 12th of the month, or the 27th of the month? And actually that is true if you look across our State of California. But if you separate out just those people living in the lowest income zip codes who are most likely to be food insecure, their risk of being hospitalized for low blood sugar is 27% higher in the last week of the month. So we say to ourselves, that can't really have an impact in the short term. It can for somebody with diabetes and it can for somebody with heart failure.

Eric: Okay. I'm going to ask one question. Dr. Smith sees patients in the hospital. Dr. Smith, you're on consults right now.

Alex: You're putting me on the hot seat.

Eric: I'm putting you on the hot seat. How many of your patients screen positive for food insecurity that you saw?

Alex: I have no idea. We didn't screen them.

Hilary: You're going to have to come back and tell us.

Alex: But this is a good question. I was going to ask a similar question...

Hilary: Well, actually let me say, the Medicare total health assessment now has a two-item screen for food insecurity so that older adults are getting at least theoretically screened once a year for food insecurity.

Alex: That's part of their annual visit.

Hilary: Yes.

Eric: And we just did a podcast with William Dale on geriatric assessment in oncology and nutrition. We should include food insecurity. It should be part of a complete geriatric assessment.

Alex: Absolutely.

Eric: On the palliative care assessment.

Alex: On the palliative care end of the spectrum, I want to ask, is there anything about ... We've talked quite a bit about geriatrics, outpatients, preventing longer term harms like hyperglycemia, et cetera, longer term preventative issue. How about for people who are living with serious life limiting illness or nearing the end of life? Is there anything about food insecurity in those population?

Hilary: Yeah. I'm going to answer that by answering the opposite, which is ironically if you look at the older adult population, within that older adult population, the people who are most likely to be food insecure are actually the youngest of the older adult population, and there's been a lot of trying to figure out why this is. The reason is because clinicians and clinical support and communities and social workers, et cetera, often address a patient's food insecurity as they get more frail without even realizing it. And the reason why is the trigger for connecting with a home delivered meal, for example, is around frailty, not around food insecurity or is around referral to hospice for a terminal diagnosis and not around food insecurity.

Hilary: But all of these interventions that we put in place as people become more frail often are the fix and I think it's really important for people to understand that we are very good in some situations in addressing this problem. We just have to get better at it, and we have to get better at doing it early in a disease course rather than really latent disease course when people sometimes have other resources that they can bring to bear like enrollment in a hospice program.

Hilary: Now, once you're talking about enrollment in a hospice program or a terminal diagnosis, the issue that we come up against there is that people often take a terminal diagnosis as an opportunity to reflect on their eating and we're often instructing people in that setting to make very expensive changes in their dietary intake, both to help treat their disease, but also because we are often treating the side effects of disease with specific foods, particularly in a cancer setting. So for all of these reasons, as people get terminal diagnoses, their desire to spend money on food goes up. And so it becomes more stressful for people to be food insecure.

Alex: Absolutely. Yeah, and I don't think it's something that in palliative care. We could ask Tom Reid, our palliative care fellowship director the same question or Lynn Flint, who is the GeriPal fellowship director the same question. I suspect they're not teaching this clinically. And I think as we've heard a compelling arguments today, the pendulum needs to shift there.

Hilary: Hear, hear.

Eric: We're going to do a magic wand. You have a magic wand right now and you can make one change.

Hilary: SNAP. SNAP is the most effective program we have.

Eric: What would you change at SNAP?

Hilary: All older adults would be enrolled in SNAP if they met basic eligibility criteria and they may be maintained on their SNAP benefits for as long as they were eligible without the stigma that is often felt by older adults enrolling in SNAP benefits, without the operational complexity of getting to the SNAP office to enroll, without all of the logistical complications of translation and limited health literacy that really make it complicated for many older adults to get on benefits and maintain it. But once you're on them, SNAP, it is the answer. There are SNAP eligible stores in every county in the U.S. There are SNAP offices in every state in the U.S. And so that is really the most cost efficient answer we've got.

Eric: Great.

Alex: Great.

Eric: Well, Hilary, I want to thank you for joining us on this podcast.

Alex: Thank you so much, Hilary.

Hilary: Thank you for inviting me.

Eric: But before we leave, Alex, I know he wants to do a little bit more of the song.

Alex: A little bit more Cat Stevens? (singing)

Alex: And with that, again, Hilary, big thank you. Big thank you to all of our listeners. If you have a moment, please rate us on your favorite podcasting app if you haven't done so already.

Eric: Thank you to Archstone Foundation. Thanks again, Hillary.

Hilary: Thank you guys. It was fun.

Alex: Bye everybody.

Eric: Bye.