Editor’s Spotlight/Take 5: Do Patients Reporting Fractures Experience Food Insecurity More Frequently Than the General Population?

They say that there’s nothing new under the sun, and most of the time they’re probably right. But every once in awhile, they’re not. In this month’s Editor’s Spotlight, I’m excited to share a wonderful paper [6] on a topic that—despite its fairly profound importance—I’ve never seen studied in an orthopaedic journal before.

The topic is food insecurity. While there have been more studies than one can count that have suggested that markers of malnutrition (like low serum albumin levels) are associated with postoperative infection or other complications, studies of association like that can take us only so far. By the time a patient has malnutrition at that level, it’s often associated with frailty or other comorbidities, and it’s not at all clear that dumping calories in—even good calories—will change the big picture by very much. It amazes me that so little has been done to look deeper, to the root cause, as defined by the United States Department of Agriculture: “The lack of consistent access to enough food for every person in a household to live an active, healthy life” [4].

A fairly shocking paper in this month’s Clinical Orthopaedics and Related Research® found that almost one in five patients with fractures also experience food instability [6]. Food insecurity in the United States overall is much less common—closer to one in 10 individuals [10]. The data in this CORR® paper came from the National Health Interview Survey, an enormous annual undertaking that evaluates about 90,000 individuals from some 35,000 households, run by the Centers for Disease Control and Prevention [2]. This survey is representative of the civilian, noninstitutionalized United States population and allows us to discern nationwide trends in physical, economic, and psychosocial health factors.

Aside from that eye-popping one-in-five statistic for patients with fractures, this multi-institutional collaboration lead by Heather A. Vallier MD of Case Western Reserve University in Ohio identified a few associated factors that can guide clinicians in screening efforts. After controlling for relevant confounding variables, patients between the ages of 45 and 64 had a fourfold increase in the odds of having food insecurity. Additionally, patients with lower incomes or lower educational attainment, patients without insurance, patients who smoked cigarettes, and Black patients were at much higher risk than others.

This isn’t hypothetical stuff. If a person has to choose between money for food, money for a cab fare to the clinic, or money for antibiotics for that inflamed-looking surgical incision, well, that’s not a choice we’d like to see our patients make. And the problem may go deeper—we know that individuals who have experienced intimate partner violence are more likely to have fractures [9], and food insecurity is tightly bound up with intimate partner violence [8]. These are associations, not causal links, but it isn’t hard to imagine a causal connection between food insecurity and intimate partner violence if one thinks through the main Bradford Hill criteria for causality [1], and indeed some analyses support just such a causal link [5].

The good news is this: Making a meaningful, life-changing difference in the life of your next patient with a fracture requires you to do no more than ask one question.

Join me to learn what that question is in the Take 5 interview that follows with Heather A. Vallier MD, senior author of “Do Patients Reporting Fractures Experience Food Insecurity More Frequently Than the General Population?”

But before we get there, I’ll make a quick plug for the special issue in which Dr. Vallier’s important work appears. This month’s Clinical Orthopaedics and Related Research® contains selected proceedings from the 2022 International Consortium for Mental and Social Health in Musculoskeletal Care. If you’re not familiar with this consortium, I encourage you to dip into the work they’re publishing here this month. This suggestion holds regardless of what kind of bone doctor you are, because that’s just the point: These papers point us to specific, practical ways that we can—and they paint a compelling picture about why we must—look past the bones we’re treating to the whole person who is using them.

Take 5 Interview with Heather A. Vallier MD, senior author of “Do Patients Reporting Fractures Experience Food Insecurity More Frequently Than the General Population?”

Seth S. Leopold MD: Congratulations on this eye-opening and very practical study. I know that there are screening tools for food insecurity, but surgeons are under constant pressure to use more and more survey and outcomes instruments. Can you give me one question that the busy surgeon can use to get a sense for whether (s)he needs to go deeper on the topic of food insecurity with a patient, and share some experiences you’ve had using it?

Heather A. Vallier MD: Thanks for your interest in this important topic. It is common for surgeons to be under stress regarding insufficient time, especially in the outpatient clinic where more outcomes instruments are being advocated recently. I recommend using this sentence, which is simple to remember and encompasses adults and their children, if applicable: “In the last 12 months, were there times when the food for you and your family just did not last and there was no money to buy more?” This question has been validated in several countries (USA, Canada, and Australia) and recommended in an official policy statement from the American Academy of Pediatrics [3] for adults and their children.

Dr. Leopold: From talking to surgeons, I get the sense that sometimes we’re afraid to ask questions because we fear getting an answer we need to act on. How can you reassure surgeons that your question is one “not to fear”? That is, is there a practical set of responses a surgeon can take if the patient answers in the affirmative that won’t cause that surgeon to have to duck out of clinic for a 45-minute conference call with a squadron of social workers?

Dr. Vallier: It is true that the questions we are often ill-prepared to answer, and which may take much more time to act on, are the important ones that may really meet the needs of patients and their families. Our team has developed internal resources through a Trauma Recovery Services (TRS) program, which is accessible in inpatient and outpatient settings. The TRS professionals provide education and community referrals as indicated. If your clinical team colleagues can develop a brief electronic and printed list of these resources, it can be given to patients with a short explanation by a physician extender, nurse, or other team member.

Dr. Leopold: On the flip side, many facets of social health—perhaps including food insecurity—carry a social stigma. How can we minimize the risk of shame so as to maximize the likelihood that a patient will tell us that food insecurity is a problem in his or her life, if indeed it is?

Dr. Vallier: This is an important point, and one that I have only recently come to understand. Once I have some rapport with a new patient, engendering trust, I embark on topics of importance, including mental health, substance use, housing, food, and related issues. I frequently temper my inquiry with a statement such as, “Every day I meet a lot of people who have difficulty accessing food for themselves and their families…” My sense is that the time spent together to develop the relationship, exhibiting empathy and compassion, may mitigate the tendency for patients to feel shame or stigma. Nevertheless, this is an area of concern, and individuals vary based on age, culture, ethnicity, and countless other elements, which may hinder a complete exchange of relevant information.

Dr. Leopold: The only other paper I recall reading that touched on this topic was a modeling study about the harms of using BMI (among other things) to screen patients considering joint replacement [11]. In a Take 5 interview like this one, the senior author of that paper raised my consciousness about the relationship between food deserts and people with high BMI who may nonetheless be poorly nourished and perhaps food insecure [7]. I know you didn’t study this specifically here, but how might you use that concept as you employ the findings of your study in everyday practice?

Dr. Vallier: Malnourishment is common among patients who have experienced musculoskeletal trauma, and often occurs in those with high BMI. Unhealthy food choices and/or eating habits underlie this phenomenon. Food insecurity may also play a role. I raise attention to the importance of nutrition with all my patients. We use a smartphone app with educational materials, including nutrition, and we specifically recommend increased protein intake, generic multivitamin, and ample calcium and vitamin D. This information is also available in printed format.

Dr. Leopold: Food insecurity rarely travels alone; it’s one of many social stressors that patients who have experienced physical trauma are more likely to be exposed to. Your paper reminded me of a recent one about intimate partner violence, which also is disconcertingly common in fracture clinics [9]. How does the good trauma surgeon manage to look after the whole patient, given the diversity, severity, and interactions of social stressors like these?

Dr. Vallier: Trauma is usually not a unique injury event at one point in time. Rather, a lifetime of trauma, ranging from acute or chronic injury, and regular, possibly daily, traumatic experiences arising from adverse social circumstances and events is more typical than is generally recognized. Implementing a basic screening tool for social determinants of health into new patient visits is one way to identify patients with a history of prior trauma. However, unless a trusted member of the healthcare team explains why these elements are solicited, participation may be limited. Employing a team of colleagues in a trauma system, both in the inpatient and outpatient settings, may foster more opportunities to identify patient risks and unmet needs and implement services internally or externally.

Enhancing the education of all physicians, nurses, and other team members about mental and social health opportunities—the frequency, symptoms and signs, and strategies for intervention—will help mitigate this public health burden. If we each serve as a champion in this space, these issues will become more widely understood and appreciated.

Heather A. Vallier MD