Food Insecurity and Pregnancy: Addressing Inequities through “Food is Medicine” Initiatives
November 22, 2024
Overview
Women are disproportionately affected by food insecurity, and these disparities are even more pronounced during pregnancy, with some studies estimating that one in five pregnant people face food insecurity. There is growing interest in positioning food insecurity as a health issue requiring a health care response. Federal and state programs that center “food as medicine” show promise in addressing the negative health outcomes that can result from food insecurity, improving both maternal and child health outcomes.
Food Insecurity is a household-level economic and social condition of limited or uncertain access to sufficient food, or food of adequate quality, to meet one’s basic needs. In 2023, one in seven American households (13.5 percent) experienced food insecurity, affecting 47.4 million people; a number that has steadily increased over the past few years. The USDA estimates that annual at-home-food prices increased 5 percent in 2023, compared to the usual 2.5 percent. Additionally, from 2019 to 2023, in the context of the COVID-19 pandemic and global conflicts disrupting the global food supply chain, U.S. food prices increased overall by 25 percent. These increased prices force many families to choose between sufficient nutrition and paying for rent, utilities, and other necessities.
The CDC classifies food insecurity as a social determinant of health that is influenced by intersecting factors such as income, employment status, race and ethnicity, and location. For example, compared to the national average of 13.5 percent, Black and Hispanic households statistically face higher rates of food insecurity, with reported rates of 23.3 percent and 21.9 percent respectively. These higher rates reflect broader and complex systemic issues rooted in structural racism and income inequality, in turn, further perpetuating economic and health disparities.
Location also plays a role in food security. Compared to suburban areas, people living in urban and rural areas are more vulnerable to food insecurity, with rates of 15.7 percent and 15.4 percent. These areas often lack food retailers, limiting access to fresh and healthy food. Moreover, societal and community norms, as well as stigma, can shape and limit available resources in communities as well. People living in these areas are also more likely to face negative impacts on their physical and mental health, including but not limited to, a higher risk of chronic disease and other preventable health issues.
Women, particularly those living alone or heading single-parent households, are disproportionately affected by food insecurity. Women living alone experience a food insecurity rate of 16.2 percent, while single-female-headed households face rates as high as 34.7 percent. While a complex issue, these rates can be attributed to the result of socio-economic instability and gender inequality, exacerbating the challenges of food access for women. These disparities are even more pronounced during pregnancy, with some studies estimating that one in five pregnant people face food insecurity.
Research shows that a well-balanced, healthy diet is especially important for pregnant individuals. Babies born to food insecure people are more susceptible to adverse health outcomes, including low birth weight, premature birth, and developmental delays; while the parent is more likely to develop health-related challenges. Food insecurity while pregnant can lead to short and long term health consequences, such as mental health conditions and disordered eating. Additionally, there is a higher risk of developing a chronic disease, as individuals may rely on inexpensive, less nutrient dense foods that can contribute to gestational weight gain and diabetes. Over the past three decades, chronic diseases, specifically hypertension and diabetes, have significantly increased among pregnant people. Chronic disease plays a significant role in increasing the risk of complications during pregnancy and maternal morbidity and mortality.
There is growing interest in positioning food insecurity as a health issue requiring a health care response. Health related social needs, which are non-medical factors that can impact health, such as food insecurity, have been prioritized under Medicaid, the federal-state program that provides access to health care for people with lower incomes. In 2023, the Department of Health and Human Services developed a Food is Medicine initiative, in response to a congressionally funded initiative and has partnered with other organizations to advance this initiative.
Several policy initiatives have also been introduced at the state level to combat food insecurity while supporting health and wellness, including Oregon, which expanded the Oregon Health Plan (Oregon Medicaid) services to include nutrition education and counseling, as well as cooking education. “Food as medicine” initiatives like these recognize that insuring adequate nutritional intake is health care. “Food as medicine” policies typically focus on providing medically tailored meals, nutritional counseling, and prescriptions for fresh produce.
The concept of “food as medicine” has additionally been identified by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). People enrolled in Medicaid are typically eligible for WIC based on income, and pregnancy is one of the eligibility criteria for WIC. The WIC Farmers’ Market Nutrition Program (FMNP) is also increasing healthy food access in addition to WIC benefits, with coupons for items such as fresh produce and local honey for eligible participants.
Creating a stronger local food system can also help increase access to nutritious food, particularly in areas considered food deserts. In 2019, increased funding from government entities resulted in the establishment of farmer’s markets through the USDA’s Farmers Market Promotion Program and the Local Food Promotion Program. In California, the state’s Department of Health has partnered with WIC to catalyze their Farmer’s Market Nutrition Program (FMNP), increasing the accessibility of fresh produce for pregnant individuals. These partnerships have expanded to include community-based organizations that provide nutrition education and help foster healthier food choices. Stronger local food systems not only increase access to nutritious food, particularly when partnered with programs like the WIC FMNP, but they positively impact the local economy as well.
Providing individuals with prepared medically tailored meals that take their medical conditions or specific needs into account, is another approach to addressing the potential health harms that can result from food insecurity. For pregnant people, these meals can help ensure that they receive the recommended nutrition needed for a healthy pregnancy, fetal development, and post-partum life. In addition to managing chronic diseases, medically tailored meals can also help fight against the possibility of pregnancy related complications.
Several states reimburse medically tailored meals through Medicaid. Massachusetts is a leader in putting the “food as medicine” approach into policy and practice. Massachusetts Medicaid recipients who are experiencing difficulty managing a chronic illness, or who are pregnant, can receive “prescriptions” from medical professionals for individually tailored meals. By integrating medical nutrition therapy in the form of prepared meals, Massachusetts Medicaid provides a proactive and impactful solution to promote healthier outcomes for its residents, including pregnant people. Massachusetts “food as medicine” initiatives additionally partner with other social services to ensure that all social needs are being met, creating an integrated, holistic approach to care. These collaboratives, and policy driven efforts, support low-income individuals, reduce health inequities, and improve the health and well-being of the parent and baby, fostering the ability for both to thrive.
A similar approach involves the prescription by a health care provider of produce boxes. In economically-disadvantaged areas, access to fresh produce can be difficult, and studies have found that food insecure people in those circumstances may default to less nutritious food because it is cheap and convenient. In a pilot program in Flint, Michigan, physicians prescribed produce boxes for pregnant people that they then obtained at their local farmers market or through a mobile market. A follow-up study confirmed the program’s effectiveness in improving the consumption of healthier foods by the participants.
Having one’s nutritional needs met while pregnant is imperative both for the health of the pregnant person, and the health of their unborn child. Programs like those outlined here that address the inequitable negative health outcomes that can result from food insecurity, can address these gaps and can greatly improve maternal and child health outcomes.
This post was written by Clare Santas, Senior Program Coordinator, Network for Public Health Law and Kathleen Hoke, Director, Network for Public Health Law — Eastern Region.
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