THE PREVALENCE and effects of hunger CLINICAL INVESTIGATIONS. The Prevalence and Effects of Hunger in an Emergency Department Patient Population

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1 ACADEMIC EMERGENCY MEDICINE November 1999, Volume 6, Number CLINICAL INVESTIGATIONS The Prevalence and Effects of Hunger in an Emergency Department Patient Population MARGARET A. KERSEY, BA, MARY SUE BERAN, MD, PAUL G. MCGOVERN, PHD, MICHELLE H. BIROS, MS, MD, NICOLE LURIE, MD, MSPH Abstract. Objectives: Little is known about the prevalence and health effects of hunger among ED patients. The objectives of this study were to determine the prevalence of hunger among patients in a large urban ED and to examine whether it has adverse health effects. Methods: A survey about hunger, choices between buying food and buying medicine, and adverse health outcomes related to food adequacy over the preceding 12 months was administered to a convenience sample of adult non-critically ill ED patients from afternoon and evening shifts. The study was conducted in the ED of Hennepin County Medical Center in Minneapolis, Minnesota. Results: Of the 302 eligible patients who were asked to participate, 297 (98%) agreed. Eighteen percent reported not having enough to eat at least once in the preceding 12 months: 14% reported that they had gotten sick as a result of not being able to afford their medicine, resulting in an ED visit or hospital admission 50% of the time. Predictors of making choices about buying food vs medicine include having a chronic health condition, lack of private health insurance, having a reduction in food stamps, having an annual income less than $10,000, and lack of alcohol use. By patient report, a reduction in food stamps was a predictor of ED visits and hospitalizations as a result of making choices about buying food over medicine. Conclusion: The ED patients in this urban setting have high rates of hunger and many must make choices between buying food and medicine, which patients report results in otherwise preventable ED visits and hospitalization. Loss or reduction of food stamps is associated with increased hunger and increased perceived adverse health outcomes as a result of not being able to afford medicine. Key words: hunger; uninsured and underinsured population; emergency department; medical noncompliance. ACADEMIC EMERGENCY MEDICINE 1999; 6: THE PREVALENCE and effects of hunger among ED patients have not previously been formally recognized as barriers to health and health care delivery. While overt malnutrition is From the University of Minnesota Medical School Minneapolis (MAK, NL), Departments of Medicine (MSB) and Emergency Medicine (MHB), Hennepin County Medical Center, and the University of Minnesota School of Public Health (PGM), Minneapolis, MN. Dr. Lurie is currently at the Department of Health and Human Services, U.S. Government, Washington, DC. Received March 3, 1999; revision received June 30, 1999; accepted July 15, Presented at the SAEM annual meeting, Boston, MA, May Supported in part by the Allina Foundation and the HCMC Department of Emergency Medicine Research Fund. Address for correspondence and reprints: Nicole Lurie, MD, MSPH, Principal Deputy Assistant Secretary of Health, Department of Health and Human Services, 200 Independence Avenue SSE, Room 716G, Washington, DC The views represented in this paper are those of the authors only and do not necessarily represent the views of the Department of Health and Human Services. known to have adverse health effects, 1,2 hunger and food insecurity are just recently becoming recognized as legitimate health issues. This issue has become particularly salient since 1998, as millions of Americans have left the welfare roles as a result of the Personal Responsibility and Work Opportunity Reconciliation Act. 3 Implementation of the act has been accompanied by reductions in receipt of food stamps for many low-income families. Nelson et al. recently reported that among adult patients using inpatient or outpatient services in an urban county hospital, 13% reported not eating for an entire day in the prior year because they did not have enough money for food. 4 A pediatric study at the same institution found the prevalence of hunger to be 6.6%, with a further 32.7% of patients at risk for hunger. 5 Although the adult study was initiated because of a finding of adverse health outcomes among diabetic patients who experienced hunger or food insecurity, it was not designed to examine the relationship between reductions in food stamps and poorer health out-

2 1110 HUNGER IN ED Kersey et al. HUNGER IN ED PATIENTS TABLE 1. Patient Characteristics (n = 297) Age mean SD [range] [16 99] yr Race White 106 (36%) African American 127 (42%) Native American 25 (8%) Asian 3 (1%) Hispanic 14 (5%) Other 15 (5%) Annual income <$10, (48%) Gender male 135 (46%) Education <12th grade 73 (25%) High school graduate 177 (60%) College graduate 40 (14%) Cigarette use 139 (47%) Alcohol use 126 (42%) Illicit drug use 27 (9%) Health insurance None 72 (26%) Public 143 (52%) Private 61 (22%) Chronic illness Diabetes 33 (11%) Hypertension 72 (25%) Asthma 55 (19%) Heart problems 56 (19%) Depression 93 (32%) Other 110 (38%) Health status excellent or good 160 (54%) Reported very or somewhat easy to get medical care 226 (76%) comes. In addition, to our knowledge, no recent study has attempted to document the prevalence or effects of hunger and food insecurity on an ED patient population. This is of significance because a large segment of the low-income and uninsured population use EDs as their source of primary care. 6,7 Our study extends the work of Nelson et al. 4 by examining the prevalence of hunger and food insecurity among patients seeking care in an ED. Furthermore, it examines the degree to which lowincome patients make overt choices between buying food and buying medication, and whether such tradeoffs lead to problems due to failure to take medications as indicated. METHODS Study Design. This study was an interview survey of a convenience sample of adult ED patients to determine the prevalence of hunger and whether it was perceived to have resulted in adverse health outcomes. Prior to initiation, the study was reviewed and approved by the institutional human subjects review board. Study Setting and Population. The survey was conducted at the Hennepin County Medical Center (HCMC) ED. HCMC is a 435-bed public teaching hospital in downtown Minneapolis, Minnesota. The annual ED census is approximately 90,000 patients. The study population included all adult ED patients who were awaiting care, test results, or transfer. Patients were excluded if they were under 18 years of age, were non-english-speaking, had any alterations in mental status, or were medically unstable or otherwise too ill to participate. Study Protocol. Data were collected during faceto-face interviews in treatment areas of the ED. Participation was voluntary. The interviewers were medical students and ED clerks. All were trained to administer the survey using a written script. Data were collected between April and August 1998, during two- to four-hour blocks in the afternoons and evenings during a total of ten interview days. While the identification and selection of patients for study were systematic, the dates and times of data collection were chosen for convenience. We attempted to interview all eligible patients who visited the ED during the study time periods. The interview took from 5 to 10 minutes to complete. Measures. A 28-item questionnaire* was used, including seven items that are previously validated measures of hunger and food insecurity, 8,9 health status, current medical conditions, and patients monthly out-of-pocket expenses for medications. Patients were also asked whether they had to make explicit choices between buying food and medicine ( Did you ever put off paying for medication so that you would have money to buy food? Did you ever space out the frequency of taking your medication because you couldn t afford to buy more? Have you had to make the choice between buying medicine or buying food? ), and whether these choices had resulted in any perceived adverse health outcomes consequences ( Looking back, did you ever get sick because you couldn t afford to get or take your medication, and if so, did you have to go to the emergency department or be admitted to the hospital? ). Questions about hunger, food insecurity, and choices between food and medicine were asked in relation to the previous 12 months and the previous 30 days. *The questionnaire is available from the authors on request.

3 ACADEMIC EMERGENCY MEDICINE November 1999, Volume 6, Number Patients were also asked about demographic information, including annual household income, race, level of education, presence and type of health insurance, food stamp use, including whether food stamps had been decreased or eliminated during the preceding year, and lifestyle habits (use of tobacco, alcohol, and illicit drugs). Data Analysis. We first examined descriptive statistics regarding the patient population and the prevalence of hunger, food insecurity, and the degree to which patients reported making choices between food and medicine. Using both standard tabular methods and logistic regression, we examined bivariate associations between patient characteristics and reductions in food stamps and hunger/ food insecurity and difficulty affording medications. We then examined the predictors of hunger and food insecurity, choices between food and medicine, and going to the ED or hospital because of inability to afford medicine. The independent predictors of going hungry and making choices between food and medicine were determined in forward stepwise logistic regression. We did not attempt to determine the independent predictors of ED visits or hospitalizations because of the small number of these events. All analyses were performed using SAS, version 6.12 (SAS Institute, Cary, NC). RESULTS Three hundred two patients were approached during the study, with 297 consenting to be interviewed (response rate of 98%). Patient characteristics are shown in Table 1. The mean age ( SD) was years. The patients were predominately low-income and racially diverse. The patients reported a high level of chronic illness, with 68% of the respondents reporting at least one health problem. Hunger and food insecurity items are reported in Table 2. The patients reported high levels of hunger and food insecurity, with 18% reporting that they either often or sometimes did not have enough food in their homes in the preceding 12 months. Twenty-three percent reported that they went hungry at least once during the preceding 12 months, with the same number reporting that they did not eat for a whole day at least once in the preceding 12 months; 43% of these respondents reported that this problem occurred almost every month. Of those living with children less than 18 years old (n = 122), 27 (23%) reported skipping a meal in the preceding 12 months so that the child could eat. As expected, the patients reported an even higher level of food insecurity than hunger, as food TABLE 2. Twelve-month Prevalence of Hunger, Food Insecurity, and Adverse Health Outcomes (n = 297) Food insecurity Put off paying bill to buy food 98 (33%) Received emergency food (food shelf) 86 (29%) Went to soup kitchen 61 (21%) Had enough food but not the kind desired 83 (28%) Hunger Did not have enough food 53 (18%) Did not eat for a whole day 68 (23%) Went hungry but did not eat 68 (23%) Family hunger Skipped meal so child could eat 27/122 (23%) Child skipped meal 4/122 (4%) Food stamp usage 102 (34%) Food stamps cut in preceding 12 months 59 (58%) Food vs medicine Put off buying medication for money for food 32 (11%) Spaced out frequency of taking medicine 29 (10%) Got sick because couldn t afford medicine 42 (14%) No. resulting in ED visit or hospitalization 21/42 (50%) Had to make choice between food and medicine 30 (10%) insecurity often precedes hunger. Over a fourth of the respondents reported having enough food but not necessarily the kind of food they wanted, while one third reported putting off paying a bill to buy food in the preceding year. Of the 102 respondents who had received food stamps in the preceding 12 months, 58% reported that their food stamps had been cut off or reduced in the same time period. Eleven percent of the respondents reported that they have put off buying medication to have money for food in the preceding year. This problem occurred monthly for nearly a fourth of them. Fourteen percent of all the respondents said that they have gotten sick as a result of not being able to afford their medicine, and half of those report that this resulted in an ED visit or hospital admission (21 respondents). Table 3 shows the univariate predictors of going hungry, making choices about food vs medicine, and adverse health consequences (measured as ED visits or hospitalizations as a result of having to make the choice to buy food over medicine). For regression analysis, any patient who answered yes to one or more of the three hunger questions (Table 2) was counted as hungry. Similarly, any patient who answered yes to one or more of the four food vs medicine questions was counted as making choices about food vs medicine. Predictors of increased hunger in bivariate analysis include age over 40 years, annual income < $10,000, receipt of public assistance benefits, a chronic health condition, and cigarette use. Predic-

4 1112 HUNGER IN ED Kersey et al. HUNGER IN ED PATIENTS TABLE 3. Predictors* of Hunger, Making Choices between Food and Medicine, and Health Consequences Predictors of Hunger OR (CI) Made Choices between Buying Food and Medicine OR (CI) ED Visit or Hospitalization because of Inability to Buy Medicine OR (CI) Age over 40 years 1.78 (1.07, 2.96) 1.46 (0.84, 2.55) 0.91 (0.37, 2.23) White race 0.82 (0.48, 1.40) 0.86 (0.48, 1.54) 0.51 (0.18, 1.43) Reduction in food stamps 2.01 (1.11, 3.65) 2.24 (1.19, 4.18) 2.55 (1.002, 6.47) Income <$10, (2.45, 7.54) 2.56 (1.42, 4.64) 2.02 (0.79, 5.16) Received benefits 1.79 (1.03, 3.11) 1.02 (0.55, 1.89) 0.60 (0.20, 1.79) Cigarette use 2.81 (1.66, 4.73) 2.06 (1.17, 3.64) 1.91 (0.77, 4.75) Alcohol use 1.10 (0.67, 1.83) 0.53 (0.29, 0.95) 0.64 (0.25, 1.65) Illicit drug use 1.57 (0.67, 3.70) 1.07 (0.41, 2.81) 1.81 (0.49, 6.63) Chronic health problem 2.91 (1.57, 5.38) 2.22 (1.14, 4.43) 2.11 (0.69, 6.47) *All CIs that exclude 1.0 are statistically significant at p < tors of having to make choices between buying food and medicine include the presence of chronic health problems, reduction in food stamps, income less than $10,000, and cigarette use. The only statistically significant predictor of ED visits or hospitalizations as a result of choosing food over medicine was a reduction in food stamps, although the statistical power to detect other associations was poor since there were only 21 instances of ED visits or hospitalizations. Using forward stepwise logistic regression, independent predictors of increased hunger are income less than $10,000 (OR = 3.63; 95% CI = 2.00 to 6.67), the presence of a chronic health condition (OR = 2.34; 95% CI = 1.18 to 4.62), and smoking (OR = 2.44; 95% CI = 1.33 to 4.45). Independent predictors of making choices between food and medicine are income less than $10,000 (OR = 2.82; 95% CI = 1.48 to 5.36) and the presence of a chronic health condition (OR = 1.88; 95% CI = 0.93 to 3.78). All are statistically significant at p < 0.05, except for chronic health condition as a predictor of making choices about buying food vs medicine, in which p = DISCUSSION These data suggest a high prevalence of hunger and food insecurity among patients attending an urban public hospital ED. In fact, our study found a higher prevalence of hunger than that of Nelson et al., which was conducted at the same institution. 4 However, our study was conducted only on ED patients, whereas Nelson et al. interviewed clinic patients and hospital inpatients. Several studies have demonstrated that patients with fewer resources and more chaotic lives are more likely to use the ED for primary care than those with more resources and stable life circumstances. 6,7 We believe that the same instability and poverty that may lead a patient to seek primary care in the ED may also contribute to ED patients increased hunger and food insecurity. These data extend the work of others by documenting that hunger and food insecurity are significantly associated with the need for patients to make choices about buying food vs medicine. By patient report, a substantial proportion of these choices resulted in ED use or hospitalization, presumably because of worsening of a chronic health condition. Shea et al. 10 previously documented the relationship between hypertensive crises in EDs and access to care. These data suggest that beyond basic access to care, simultaneous access to medicines and adequate food would help avert adverse outcomes, at least as manifested by ED or hospital admission. As mentioned above, large numbers of people have left welfare roles since 1998 as a result of the Personal Responsibility and Work Opportunity Reconciliation Act. 3 Although they may remain eligible for Medicaid and food stamps, they do not always receive these benefits. These data are a reminder that for low-income individuals, we cannot assume that there is a guarantee of adequate access to basics such as food. Results of a recent large nationwide cross-sectional study (NHANES III), which was conducted before the Personal Responsibility and Work Opportunity Reconciliation Act was enacted, suggest that an estimated 4.1 million Americans go hungry at some point each year, with an additional 4% of Americans experiencing food insecurity at some point. 11 We found it interesting that cigarette use was an independent predictor both of hunger and of making choices between buying food and medicine, although it did not achieve significance as a predictor of adverse health outcomes. The fact that our subjects were willing to go hungry or without medicine in order to smoke speaks to the powerfully addictive nature of nicotine. In contrast, those admitting to alcohol use were significantly less likely to report having to make choices between food and medicine than those not using any alcohol.

5 ACADEMIC EMERGENCY MEDICINE November 1999, Volume 6, Number Hunger and food insecurity remain significant problems among low-income adults. In addition, their sequelae are not limited to the discomfort of an empty stomach, but rather extend to the domain of health care and poor health outcomes. Low-income adults frequently receive their medical care in the ED. The possibility that our patients have had to make choices between food and medicine should be considered, and local resources (food banks or food shelves, other community services) offered when needed and available. Further attempts to reduce food stamps without ensuring adequate income to buy food are likely to result in further adverse health events. LIMITATIONS AND FUTURE QUESTIONS Several limitations to this study must be acknowledged. First, it was conducted at a single institution, and findings are based entirely on the selfreport of participating patients. Second, because of the need to use unpaid interviewers, we did not randomly sample patients presenting at all time periods within a 24-hour period. Further, while we attempted to approach all prospective subjects, it is possible that the interviewer was unaware of some potential subjects during busy time periods. The ED hourly census is unpredictable. However, based on the average hourly patient census in this ED, we believe we approached approximately 70% of all eligible patients in the ED during enrollment hours. We therefore estimate that this potential sample loss was quite small. Third, our sample size was relatively small, and we may not have had sufficient power to detect additional associations. This is particularly the case for predictors of going to the ED or being hospitalized. A further limitation was that we limited our sample to English speakers. Because Alaimo et al. found that the highest incidence of reported hunger was among non-english-speaking Hispanics, 11 we may have underestimated the severity of the problem. While we were also limited to self-report, at least one recent study has found that self-reported hunger is well correlated with low intake of required nutrients. 12 If anything, we theorized that patients might be more likely to underreport than overreport their hunger and food insecurity, as people may not want to admit to such a problem. Indeed, at least one study of hunger in elders reported that in-depth interviews revealed that many elders are likely to underreport their hunger and food insecurity. 13 Unlike the questions about hunger and food insecurity, our questions about choices between food and medicine and health effects had not been previously validated. One question in particular, about whether patients had ever gotten sick as a result of not being able to afford their medicine so they could buy food, may be open to question because we did not have any explicit criteria to define sick. However, that language was selected as the most understandable after extensive testing of various approaches to questioning individuals in ED, food shelves, senior centers, and soup kitchens. The fact that 50% of those who described themselves as having gotten sick either were seen in the ED or required hospitalization suggests that the question has at least some face validity. We did not ask about putting off buying medicine to pay for other items, such as shelter, clothing, or cigarettes, and therefore did not question patients about competing demands for limited financial resources. The trade-off between food and health that we report may therefore not be direct but, rather, multifactorial. Although these items would indeed provide valuable information, they are not the focus of our paper, but would be excellent research questions for future studies. CONCLUSIONS Emergency department patients in our urban setting have high rates of hunger and many must make choices between buying food and medicine. Many believe that these choices have had an adverse effect on their health, resulting in ED visits and hospitalizations. Loss or reduction of food stamps is associated with increased hunger and increased perceived adverse health outcomes as a result of not being able to afford medications. The authors thank JeRay Johnson and Elizabeth Trinity for their help with patient interviewing. References 1. Steffee WP. Malnutrition in hospitalized patients. JAMA. 1980; 244: Roubenoff R, Roubenoff RA, Preto J, Balke CW. Malnutrition among hospitalized patients: a problem of physician awareness. Arch Intern Med. 1987; 147: Jones JY, Richardson J. Federal Food Programs: Legislation in the 104th Congress: Congressional Research Report for Congress. Washington, DC: Congressional Research Service, Oct 29, Document ENR. 4. Nelson K, Brown ME, Lurie N. Hunger in an adult patient population. JAMA. 1998; 279: Cutts DB, Pheley AM, Geppert JS. Hunger in midwestern inner-city children. Arch Pediatr Adolesc Med. 1998; 152: Baker DW, Stevens CD, Brook RH. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA. 1994; 271: Pane GA, Farner MC, Salness KA. Health care access problems of medically indigent emergency department walk-in patients. Ann Emerg Med. 1991; 20: Hamilton WL, Cook JT, Thompson WW, et al. Measuring Food Security in the United States, Household Food Security in the United States: Summary Report of the Food Security

6 1114 HUNGER IN ED Kersey et al. HUNGER IN ED PATIENTS Measurements Project. Alexandria, VA: USDA Food and Consumer Service, Sept Kendall A, Olsen CM, Frongillo EA. Validation of the Radimer/Cornell measures of hunger and food insecurity. J Nutr. 1995; 1225: Shea S, Misra D, Ehrilich MH, Field L, Francis CK. Predisposing factors of severe, uncontrolled hypertension in an inner-city minority population. N Engl J Med. 1992; 327: Alaimo K, Briefel RR, Frongillo EA, Olsen CM. Food insufficiency exists in the United States: results from the Third National Health and Nutrition Examination Survey (NHANES III). Am J Public Health. 1998; 88: Rose D, Oliviera V. Nutrient intakes of individuals from food-insufficient households in the United States. Am J Public Health. 1997; 87: Wolfe WS, Olson CM, Kendall A, Frongillo EA. Hunger and food insecurity in the elderly: its nature and measurement. J Aging Health. 1998; 10: