Submitted Comments – U.S. Preventive Services Task Force (USPSTF) Draft Recommendation Statement on Food Insecurity: Screening

On behalf of the undersigned, we appreciate the opportunity to provide comments on the U.S. Preventive Services Task Force (USPSTF) draft recommendation statement on food insecurity screening. The pediatricians, health services researchers, and child health policy experts at Children’s HealthWatch seek to achieve health equity for young children and their families by advancing research to transform policy. That includes dismantling systems of institutionalized discrimination and inequity, both at the root of social circumstances (i.e., poverty) that reflect in the form of food insecurity. Our work begins with research through interviewing caregivers of young children on the frontlines of pediatric care, in urban emergency departments and primary care clinics in five cities: Boston, Minneapolis, Little Rock, Baltimore, and Philadelphia. Since 1998, we have interviewed over 75,000 caregivers of children under four years of age and analyzed the data to determine the impact of health-related social needs (HRSN) and public policies designed to address those HRSN on the health and development of young children and the well-being of their families. Specifically, our research focuses on the interplay of factors like nutrition, housing, health care, childcare, utilities, income and wealth, employment, Adverse Childhood Experiences and Experiences of Discrimination, on young children’s health and development and their families’ well-being and economic mobility. Our research – in addition to that of others – shows that lack of access to basic needs, including food insecurity, is associated with poor child health and development, poor parental physical and mental health, higher child hospitalization rates, and learning and behavioral/emotional impairments.i,ii,iii,iv,v The health consequences of food insecurity are often compounded, as they are frequently experienced simultaneously alongside other health related social needs, like housing instability, due to limited income and resources.

For more than 25 years, Children’s HealthWatch has been a leading group advancing research and policy that has informed the healthcare sector’s approach to screening for food insecurity. In 2010, we validated a screening tool to identify individual households with young children at risk for food insecurity. The Hunger Vital SignTM (HVS) is a 2-question food insecurity-screening instrument, showing high sensitivity, specificity, and convergent validity.vi The HVS measures families’ concerns about access to food much the way health care providers check other key vital signs, such as pulse and blood pressure. Healthcare and social service providers, community-based outreach workers, teachers, and others that work with families with young children can use the HVS to identify households that may be in immediate need of food assistance. This tool has been recommended by the American Academy of Pediatrics for use at all well-child visits, and in 2017, the Centers for Medicare and Medicaid Services incorporated the HVS into its Accountable Health Communities Screening Tool.vii,viii To help with dissemination and implementation of the HVS, in 2016 we formed the Hunger Vital SignTM National Community of Practice alongside the Food Research and Action Center (FRAC). FRAC improves the nutrition, health, and well-being of people struggling against poverty-related hunger in the United States through advocacy, partnerships, and advancing bold and equitable policy solutions. The Hunger Vital Sign National Community of Practice (HVS NCoP) facilitates conversations and collective action among a wide range of stakeholders interested in addressing food insecurity through a healthcare lens.

Recommendation #1. We understand the USPSTF has reached the conclusion that there is not enough evidence to decide whether screening for food insecurity improves overall health, as the draft statement is only related to screening and interventions resulting from screening for food insecurity in the primary care setting. Though the USPSTF did not review the evidence on, and is not making a statement on, the use of valuable social services and community programs that set out to address food insecurity, we urge the USPSTF to engage in a transparent and inclusive process to further explore how its established methods for assessing the benefits and harms of a preventive intervention can be most effectively used for food insecurity moving forward. Given that the USPSTF acknowledges that there were several aspects specific to screening for social risk that complicated its assessment of the balance of benefits and harms, it is imperative that the USPSTF robustly engage the research, practitioner, policy, and patient communities to thoughtfully design and implement appropriate methods for continued assessment of the benefits of screening for food insecurity.

Recommendation #2. We agree with the USPSTF’s evidence review conclusion that brief, validated screening tools, such as the 2-item Hunger Vital Sign screener, likely have sufficient sensitivity to identify people at risk of food insecurity in healthcare settings, and interventions to improve food insecurity show promise, especially those that directly provide medically tailored meals, food, or vouchers/subsidies. However, we find the scope and inclusion criteria that led to the USPSTF’s (I) determination was too narrow, especially in excluding federal nutrition programs, and thus resulted in the small number of identified studies on the benefits and harms of food insecurity interventions in the primary care setting.

The USPSTF noted in the “limitations of our approach” section of the evidence review that it “did not examine the evidence on the effectiveness of federal programs such as WIC and SNAP, since these are not under the control of healthcare systems.” The decision to not examine the evidence related to federal nutrition programs such as SNAP and WIC contradict the USPSTF’s acknowledgment that these federal programs are integrated into the operations of healthcare systems. The evidence review explicitly included that the Veterans Health Administration, The National Committee for Quality Assurance, the CMS Innovation Center’s Accountable Health Communities Model, and most notably, the twenty-one states with approved or pending section 1115 demonstrations that provide coverage for nutrition interventions all incorporate connecting patients to community resources such as SNAP and WIC.ix,x,xi,xii In fact, states that have been granted a section 1115 demonstration invariably have a requirement that state Medicaid agencies must partner with existing state agencies and social service providers to connect beneficiaries experiencing food insecurity with programs such as the Supplemental Nutrition Assistance Program (SNAP), the Special

Supplemental Nutrition Program for Women, Infants, and Children (WIC), and Temporary Assistance for Needy Families (TANF).xiii Deliberate consideration of the robust evidence base pertaining to the health outcomes and health cost savings of participation in federal nutrition assistance and the integration of social services in healthcare is needed.

For these reasons, we judge the scope of review too narrow in only considering the included peer-reviewed studies and should have been expanded to include evidence linking studies that show screening tests are accurate with evidence demonstrating the effectiveness of federal programs, such as WIC and SNAP, as interventions that reduce food insecurity and improve health outcomes. In addition, the committee should consider administrative and healthcare data demonstrating Medicare and Medicaid beneficiaries’ enrollment in these programs.

We applaud the USPSTF for its efforts to review and synthesize the evidence on the benefits and harms of screening for and interventions to ameliorate food insecurity, the accuracy of screening tools, and the USPSTF conclusion that screening tools, such as the 2-item Hunger Vital Sign screener likely have sufficient sensitivity to identify people with food insecurity in healthcare settings. We encourage the USPSTF to:

• ensure inclusion of federal nutrition programs in the review scope
• build on its existing review by widening the scope to explore and identify evidence demonstrating the USPSTF’s accurate assumption that “providing adequate food and nutrition to those without consistent access to it due to poverty is a crucial component of overall health.”
• engage the research, practitioner, policy, and patient communities to thoughtfully design and implement appropriate methods for continued assessment of the benefits of screening for food insecurity

For healthcare decision makers—patients and clinicians, healthcare system leaders, and policymakers, among others— to truly make well-informed decisions and thereby improve the quality of healthcare services, the USPSTF needs to address the aspects identified that limited its assessment of the balance of benefits and harms.

Sincerely,

Children’s HealthWatch

Food Research & Action Center

HealthBegins

HealthBegins is a national mission-driven design and implementation firm that partners with Medicaid-serving leaders and teams to meet growing state requirements and federal standards for health care equity and social needs, and to achieve long-term impact for people and communities harmed by societal practices. HealthBegins work relies on a structural understanding and multi-level and multi-sector approach to improve social and structural drivers of health equity. HealthBegins is a social enterprise incorporated as an LLC, and is a nationally certified minority business enterprise (MBE)

Community Servings

Community Servings is a non-profit organization based in Massachusetts that provides scratch-made medically tailored meals to individuals and their families experiencing critical or chronic illness and nutrition insecurity. They are a national leader in the Food is Medicine movement through their pioneering work in providing medically tailored meals and their advocacy for integrating nutrition into healthcare. They have conducted and participated in research demonstrating the health benefits and cost savings of medically tailored meals, helped develop national standards for these programs.

The Root Cause Coalition