By Siri Chirumamilla, D.O.
This article is one of a series of articles to support the GAFP’s strategic plan initiative of advancing health equity in Georgia.
Social determinants of health (SDOH) are factors that can affect an individual’s health and quality of life. They are conditions which are present within a patient’s everyday life and environment. Screening tools from the AAFP and CMS can identify and stratify SDOH in several areas—including food insecurity, housing instability, financial strain, employment, mental health, substance abuse, etc.1,2
As primary care physicians, we must consider not only the downstream impacts of chronic medical diseases upon patients, but also the upstream factors that contribute to the development of these very diseases. Taking SDOH factors into consideration is one way to do this. In this article, I describe screening and resources for one major SDOH: food insecurity.
Why is this important? In 2019, more than 1.2 million Georgians were considered food insecure, according to research from the non-profit organization Science for Georgia.3 Persistent food insecurity has detrimental effects on chronic medical conditions such as Type 2 diabetes, cardiovascular disease, as well as the maintenance of mental health.4
Definition: According to the United States Department of Agriculture, food insecurity occurs when there is limited access to food based on diet characteristics (quality, variety, and desirability). This limited access leads to reduced eating patterns, with consequences for a patient’s continued well-being. Food security can be stratified from high food security (no issues) to very low food security (multiple issues with food access and disrupted eating patterns).
Screening: AAFP’s Social Needs Screening Tool is a patient-directed 15-item questionnaire that can be used to screen patients for SDOHs, including food insecurity.1
Resources: AAFP’s Neighborhood Navigator can be used in conjunction with identified SDOHs from the Social Needs Screening Tool to identify possible resources. The Navigator is a comprehensive database that utilizes the patient’s zip code to locate available resources within the patient’s community. Resources available to address food insecurity include options for food delivery, emergency food programs, food pantries, financial assistance, meals, and nutrition education.6 Additionally, eligible patients with a positive food insecurity screen should be directed to federal assistance. Programs to alleviate food insecurity include The Emergency Food Assistance Program, Supplemental Nutrition Assistance Program, The Commodity Food Program, The Child and Adult Food Program, The National School Lunch Program, School Breakfast Program, The Summer Food Service Program, and Women, Infants and Children program.
Considerations for practice: The AAFP’s Social Needs screening tool can be completed prior to visit or during intake. Once the SDOH screen is reviewed and discussed by healthcare provider, community resources based on the patient’s zip code and screen can be given to the patient. A close follow-up by the health care provider’s team is recommended to see if recommended resources were of assistance to the patient.
1. AAFP Social Screening Needs Short Form: https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/patient-short-print.pdf
2. CMS Accountable Health Communities Health-Related Social Needs Form: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf
3. Science for Georgia Food Insecurity Roundtable: https://www.senate.ga.gov/committees/Documents/ScienceforGeorgiaRoundtable.pdf
4. Thomas MK, Lammert LJ, Beverly EA. Food Insecurity and its Impact on Body Weight, Type 2 Diabetes, Cardiovascular Disease, and Mental Health. Curr Cardiovasc Risk Rep. 2021;15(9):15. doi: 10.1007/s12170-021-00679-3. Epub 2021 Jul 5. PMID: 34249217; PMCID: PMC8255162.
5. U.S. Department of Agriculture (USDA) Food Insecurity: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/definitions-of-food-security
6. AAFP Neighborhood Navigator: https://navigator.aafp.org/search_results/30345?widget=neighborhoodnavigator&ref=aafp.org
Dr. Chirumamilla is GAFP Resident Member. She is board-certified in family medicine and currently completing a Preventive Medicine residency.