Household Food Insecurity, Food Assistance Program Participation, and the Use of Preventive Medical Care

Year: 2003

Research Center: Department of Nutrition at the University of California, Davis

Investigator: Harrison, Gail G.

Institution: University of California, Los Angeles

Project Contact:
Gail G. Harrison, Professor
School of Public Health and Center for Health Policy Research
University of California, Los Angeles
Los Angeles, CA 90095
Phone: 310-825-3738


This study used the 2001 California Health Interview Survey (CHIS) to examine relationships between household food insecurity and the delay or absence of primary and secondary preventive medical care. Instances of prescribed care included prescription drugs, recommended medical tests, and other medical treatments among adults with certain diagnosed chronic diseases that require ongoing management (diabetes, heart disease, high blood pressure, asthma, and arthritis). The study hypothesized that food insecurity would be associated with low rates of utilization of preventive health services for adults with chronic diseases, i.e., poorer disease management as indexed by postponement or failure to get needed care. It was further hypothesized that these relationships would be stronger for adults in households with children, and that health insurance and participation in food assistance programs would mitigate these relationships.

It is well established that some types of preventive medical services reduce morbidity and save health care costs. Particularly for individuals with chronic disease, effective preventive services have been shown to markedly improve outcomes. For the individual with a chronic disease that requires ongoing medical, nutritional, or pharmacological management, foregoing or postponing medical care or the purchase of necessary drugs and supplies may result in increased rates of complications and poorer outcomes. There is now considerable descriptive literature on food insecurity at the household level, indicating that the management of scarce resources in the face of food insecurity and hunger often results in sacrificing or postponing other basic needs. To date, little attention has been given to food insecurity in relation to use of medical care although recent research suggests that food insufficiency—a measure of household difficulty in acquiring food that antedates the current food security measure—is associated with higher complication rates, poorer disease management, and increased medical care utilization among adult diabetics.

CHIS is the largest State health survey conducted in the United States. It is the only large database in the Nation that incorporates both a measure of household food security and extensive data on the preventive medical services, health insurance status, and participation in food assistance programs and other public assistance programs. The 2001 survey collected data from 55,428 households. Individual interviews were completed with one adult per household, with one adolescent (age 12-17) if present, and with a parent on behalf of one child under 11 years if present, resulting in 55,428 adult interviews, 5,801 adolescent interviews, and 12,592 parent interviews on behalf of children under 11 years. The food security measure used in the study is the 6-item screener derived from the 18-item Federal instrument. Food security questions were only asked of adults residing in households with per capita incomes below 200 percent of the federal poverty level. The author examined distributions and bivariate relationships; multivariate logistic regression analysis was utilized to examine predictors of key dependent variables.

Food insecurity among this population of low-income adults was 28.3 percent, while 8.3 percent reported food insecurity with hunger. More than one-quarter (28.9 percent) had no current health insurance, and for nonelderly adults (<65 years of age), the figure exceeded one-third (35.6 percent). Food stamp participation was only 10.2 percent among individuals in households with incomes below 130 percent of poverty. WIC participation was higher, with 58.5 percent of income-eligible (<185 percent of poverty) pregnant women reporting their own or their child's participation.

Contrary to the hypothesis, there was no consistent relationship between living in a food-insecure household and several basic preventive indicators, including having had a flu shot in the last year, and several screening indicators including mammograms, Pap smears, stool blood tests, and bone density screening. There was a significant association of food insecurity with never having had a blood cholesterol check or an endoscopic colon cancer screening for both men and women, or having had a prostate-specific antigen test (which helps detects prostate cancer) in men over 40.

Food-insecure adults reported significantly higher utilization of medical care, including number of doctor visits and use of an emergency room in the previous year. On the other hand, adults in households reporting hunger were more likely to have had their last dental visit more than 5 years ago than adults in food-secure households.

Among adults with diagnosed chronic disease, there was a striking and consistent relationship between food insecurity, particularly food insecurity with hunger, and the likelihood of postponing or failing to acquire prescriptions or obtaining recommended care or treatment for the disease. There was also a clear and significant relationship, across all diseases examined, between food insecurity and an emergency room visit for complications of the disease in the previous year. In multivariate models, the relationships remained significant when controlling for income, age, gender, ethnicity, family type, and health insurance, with food-insecure individuals two to five times more likely to have postponed or foregone needed care. Lack of health insurance coverage was the strongest predictor of failure to obtain or postpone care, but food insecurity remained independently predictive, in models controlled for income.

Based on these preliminary analyses, it appears that food insecurity, particularly food insecurity with hunger, is associated with postponing or foregoing medical care, including prescription drugs, for low-income adults independent of other contributing factors. An association was also found for higher medical care utilization, including the likelihood of seeking emergency room care for the disease in the previous year. These relationships are strikingly consistent across all chronic conditions examined.