Food Insecurity Is Common in the Orthopedic Trauma Population at a Rural Academic Trauma Center

Abstract

Background

Food insecurity is an increasingly recognized public health issue. Identifying risk factors for food insecurity would support public health initiatives to provide targeted nutrition interventions to high-risk individuals. Food insecurity has not been investigated in the orthopedic trauma population.

Methods

From April 27, 2021 to June 23, 2021, we surveyed patients within six months of operative pelvic and/or extremity fracture fixation at a single institution. Food insecurity was assessed using the validated United States Department of Agriculture Household Food Insecurity questionnaire generating a food security score of 0 to 10. Patients with a food security score ≥ 3 were classified as Food Insecure (FI) and patients with a food security score < 3 were classified as Food Secure (FS). Patients also completed surveys for demographic information and food consumption. Differences between FI and FS for continuous and categorical variables were evaluated using the Wilcoxon sum rank test and Fisher’s exact test, respectively. Spearman’s correlation was used to describe the relationship between food security score and participant characteristics. Logistic regression was used to determine the relationship between patient demographics and odds of FI.

Results

We enrolled 158 patients (48% female) with a mean age of 45.5 ± 20.3 years. Twenty-one patients (13.3%) screened positive for food insecurity (High security: n=124, 78.5%; Marginal security: n=13, 8.2%; Low security: n=12, 7.6%; Very Low security: n=9, 5.7%). Those with a household income level of ≤ $15,000 were 5.7 times more likely to be FI (95% CI 1.8-18.1). Widowed/single/divorced patients were 10.2 times more likely to be FI (95% CI 2.3-45.6). Median time to the nearest full-service grocery store was significantly longer for FI patients (t=10 minutes) than for FS patients (t=7 minutes, p=0.0202). Age (r= -0.08, p=0.327) and hours working (r= -0.10, p=0.429) demonstrated weak to no correlation with food security score.

Conclusion

Food insecurity is common in the orthopedic trauma population at our rural academic trauma center. Those with lower household income and those living alone are more likely to be FI. Multicenter studies are warranted to evaluate the incidence and risk factors for food insecurity in a more diverse trauma population and to better understand its impact on patient outcomes.

Level of Evidence: III

Introduction

Malnutrition is an increasingly recognized risk factor for adverse outcomes following musculoskeletal trauma. The incidence of malnutrition in the orthopedic trauma population has been reported as 18% to 45%,^1-4 but previous investigations have focused almost exclusively on the geriatric population. Other studies in both orthopedic and non-orthopedic populations have identified malnutrition as a risk factor for mortality, non-union, wound complications, readmission, and increased healthcare costs.^5-13

Malnutrition has a clear adverse effect on public health. One likely contributor to this multifactorial issue is food insecurity. The United States Department of Agriculture (USDA) defines food insecurity as a limited or uncertain availability of safe, nutritious foods and/or difficulty obtaining such foods.^14,15 This often results in poor dietary intake and has been associated with diet-related comorbidities such as type II diabetes mellitus that are known to impair healing.¹⁶ As of 2018, food insecurity was identified in 11.1% of households in the United States and noted to disproportionately impact high risk populations such as low-income communities and communities of color.¹⁷

Food insecurity is common nationwide and serves as a potentially modifiable risk factor for many of the adverse effects of malnutrition. However, the prevalence of food insecurity in the orthopedic trauma population is not yet characterized. Better understanding the commonality of this problem and its associated risk factors will allow healthcare providers to develop more targeted nutritional interventions to aid in healing and, in turn, significantly improve outcomes following musculoskeletal trauma. The present study aims to evaluate the prevalence of food insecurity and its associated risk factors in the orthopedic trauma population at a rural academic medical center.

Methods

This cross-sectional study was approved by our Inves-tigational Review Board as a quality improvement project and the surveys were completed from April 27, 2021 to June 23, 2021. We recruited patients who underwent operative fixation of an acute pelvic or extremity injury by one of four board certified trauma surgeons at a single Midwest academic level I trauma center (University of Iowa Healthcare). Patients within six months of injury completed the survey. Members of the research team approached potential enrollees both in the outpatient clinic and in the inpatient setting between surgery and discharge. The latter was intended to account for patients who may have difficulty attending follow-up appointments. There was no age restriction and verbal consent was obtained from all subjects and/or caregivers. In the case of patients under 18 years old, a parent or guardian gave verbal consent and, depending on the age of the child, completed the survey on behalf of the patient.

Surveys and Assessments

All patients responded to basic demographic questions as well as a food consumption survey (Figure 1). Food insecurity was assessed using the United States Department of Agriculture (USDA) Household Food Security questionnaire (Figure 2).¹⁴ Based on patient responses, this questionnaire generates a numerical food security score ranging from 0 to 10. Scores of 0 indicate high security, 1 to 2 marginal security, 3 to 5 low security, and 6 to 10 very low security. Food insecurity was defined as a food security score ≥ 3. For each subject enrolled, research team members also performed a chart review and calculated a Charlson Comorbidity Index (CCI) score estimating the patient’s 10-year survival percentage.^18,19

Figure 1.

Food consumption survey.

Figure 2.

USDA household food security questionnaire.

Statistical Analysis

Descriptive statistics were calculated for all continuous variables for both the Food Secure (FS) and Food Insecure (FI) cohorts. This included age, CCI score, food security score on the USDA Household Food Security Score, weekly hours worked, and time to nearest full-service grocery store. Categorical variables were also assessed including gender, ethnicity, household income level, education level, occupation, marital status, history of diabetes, and food consumption frequency. Differences between the FS and FI groups in continuous and categorical variables were evaluated using the Wilcoxon sum rank test and Fisher’s exact test, respectively. Spearman’s correlation coefficient was used to describe the relationship between food security score and participant characteristics. Odds ratios were calculated for the development of FI. Logistic regression was used to determine the relationship between patient demographics and odds ratio for FI.

Results

Demographics

158 patients (76 females, 48%) completed the survey with a mean age of 45.5 ± 20.3 years (range 4 to 89). Thirty-two patients declined to participate. Ninety-four percent of participants identified as white and 95% as neither Hispanic nor Latino. The median CCI score of all subjects was 1 (range 1 to 10) correlating to an estimated 96% 10-year survival.

Food Insecurity Assessment

Twenty-one patients (13.3%) screened positive for FI with scores ≥ 3 on the USDA Household Food Security questionnaire (Table 1). High food security was found in 124 patients (78%), marginal security in 13 (8.2%), low security in 12 (7.6%), and very low security in 9 (5.7%).

Table 1.

Food Security Scores on USDA Household Food Security Questionnaire

Security Level (USDA Score)	Number of Patients (%)
Food Secure	137 (86.7)
High (0)	124 (78)
Marginal (1-2)	13 (8.2)
Food Insecure	21 (13.3)
Low (3-5)	12 (7.6)
Very Low (6-10)	9 (5.7)

Risk Factors

Table 2 compares potential risk factors for FI. Among subjects who screened positive for FI, 67% (n=14) were female. Forty-five percent of food secure subjects were female (n=62). Mean age was 43.86 ± 15.36 (range 22-80) in the FI cohort and 45.50 ± 20.16 (range 4-89) in the FS cohort. There was no significant difference in patient demographics between the FS and FI groups. In the FI group, 81% of individuals identified as White and 70% identified as non-Hispanic. Mean CCI score for the FI and FS groups were 1.14 ± 1.65 (range 0-6) and 1.38 ± 1.92 (range 0-10), respectively (p=0.595).

Table 2.

Risk Factors for Food Insecurity

	Food Secure (%)	Food Insecure (%)	P-Value
Gender			0.072
Male	75 (55)	7 (33)
Female	62 (45)	14 (67)
Ethnicity			0.2879
Hispanic or Latino	6 (4)	2 (10)
Not Hispanic or Latino	131 (96)	19 (90)
Education Level*			0.8843
Some College to Professional	80 (59)	12 (57)
No College	56 (41)	9 (43)
Yearly Household Income*			<0.0001
≤ $15,000	13 (12)	13 (65)
> $15,000	95 (88)	7 (45)
Marital Status			0.0006
Married/Partnered	65 (47)	1 (5)
Single/Divorced/Widowed	72 (53)	20 (95)
Diabetes*			0.2671
Yes	14 (10)	4 (19)
No	122 (90)	17 (81)

*Missing responses: Education – 1; Income – 30; Diabetes – 1.

There was a significant difference in household income level between the two groups such that patients with a household income ≤ $15,000 were 5.7 times more likely to be FI (95% CI 1.8-18.1). Furthermore, patients who were widowed/single/divorced were 10.2 times more likely to be FI compared to those who are married or living with their partner (95% CI 2.3-45.6). Median time to travel to the nearest full-service grocery store was significantly longer for FI patients (t=10 minutes) compared to FS patients (t=7 minutes, p=0.0202). There was no significant difference between the groups in terms of gender, ethnicity, education level, hours worked per week, or diabetes history (Table 2). There was also no difference in food consumption practices between groups (Table 3).

Table 3.

Food Consumption Practices by Food Security

	Food Secure (%)	Food Insecure (%)	P-Value
Fast Food or Ready-to-Eat Food			0.511
< Once per week	81 (59)	14 (67)
≥ Once per week	56 (41)	7 (33)
Sugar-Sweetened Beverages			0.7304
< Once per week	51 (37)	7 (33)
≥ Once per week	86 (63)	14 (67)
Vegetables*			1
< Once per week	14 (10)	2 (10)
≥ Once per week	123 (90)	19 (90)
Fruits			0.2256
< Once per week	23 (17)	6 (29)
≥ Once per week	114 (83)	15 (71)
Protein-Containing Food			0.0733
< Once per week	5 (4)	3 (14)
≥ Once per week	132 (96)	18 (86)

*Not including potatoes.

Both time to grocery store and CCI score demonstrated statistically significant associations with food security score. Time to grocery store had a weak positive correlation (r=0.23, p=0.0041). CCI score also had a positive, yet weaker, association with food security score (r=0.16, p=0.0483). Patient age (r= -0.08, p=0.327) and hours worked per week (r= -0.10, p=0.429) demonstrated weak to no correlation with food security scores (Table 4).

Table 4.

Correlations Between Food Insecurity Risk Factors and Food Security Scores

Risk Factor	Correlation Coefficient (r)	P-Value
Age	-0.08	0.337
CCI Score	0.16	0.0483
Hours Worked per Week	-0.1	0.429
Time to Grocery Store	0.23	0.0041

Discussion

With growing recognition of the role of malnutrition in healing after surgery and trauma, it is important to identify potentially modifiable risk factors such as food insecurity. This single center cross-sectional study at a rural Midwest Level 1 trauma center demonstrated an estimated food insecurity prevalence of 13.3%. Patients with a lower combined household income and those who live alone are significantly more likely to experience food insecurity. Additionally, the severity of food insecurity positively correlated with the amount of time needed to travel to a grocery store and with the number of comorbidities as measured by CCI score.

The estimated prevalence of food insecurity in our study suggests that food insecurity may be modestly more common in the orthopedic trauma population than recent national estimates (11.1%).¹⁷ Studies in other patient populations have identified food insecurity in 11% of pregnant women,²⁰ 37% of households with children,²¹ and 40.8% of patients in primary care clinics.²² Comparing our data to these studies further suggests that food insecurity is common in orthopedic trauma patients at our institution but may not be as high as rates in other patient groups. However, even this is difficult to determine as not all studies used the same measurement of food insecurity and many opted for shorter questionnaires containing as few as one to two responses. It is possible that on a more nuanced scale such as the USDA Household Food Security survey, the rates of food insecurity in certain populations may trend closer to that seen in orthopedic trauma clinics and in pregnant women.

Prior studies on the risk factors for food insecurity have primarily focused on trends within the general population rather than individual patient populations. A recent systematic review performed by Jung et al. found that the odds for household food insecurity were 40% for female respondents to a nationwide survey and that female-led households had a 75% higher risk of food insecurity compared to male-led households.²³ We did not see a significant gender difference in the FI and FS cohorts in our study; however, the latter result is at least partly supported by our findings. Jung et al. suggested that women tend not to have the same employment opportunities as men and receive unequal pay compared to their male counterparts. As such, a female-led household with lower income has a higher probability of poverty.^23-25 In our population, the two significant risk factors for food insecurity were low household income and living alone. Though these two factors may not have been associated with gender in the orthopedic trauma population, it seems plausible that a single-income home will tend to have a comparatively lower gross income than a dual-income home thus putting an individual at a higher risk of food insecurity.

The relationship between CCI score and food insecurity also seems to correlate well with the present literature. The CCI factors in age as well as diabetes, coronary artery disease, peripheral vascular disease, and chronic kidney disease among other comorbidities. With each of these conditions, there is often a component of patient lifestyle contributing to their development and progression. The current literature has demonstrated a clear connection between food insecurity and conditions such as obesity, hypertension, dyslipidemia, and end-stage renal disease^26,27 further underscoring the lifestyle contributions to these comorbidities. As such, it follows logically that a patient with a higher degree of food insecurity is likely to have more medical comorbidities and, in turn, a higher CCI score.

Finally, our data indicated that longer times needed to travel to a grocery store were associated with more severe food insecurity scores. Though this correlation was weak, we feel that it may be at least partly unique to our patient population as a rural Midwest hospital. A 2009 study evaluated access to food in rural communities in Iowa and Minnesota finding that a relative lack of variety and high cost of food in rural counties prompted individuals to travel further to grocery stores for more desirable food. However, this added transportation costs that potentially impacted food choices.²⁸ This notion is further supported by a 2006 study that associated increased travel time to grocery stores with a higher odds ratio for obesity.²⁹ Taken together, these findings suggest that the physical separation seen in rural communities places individuals at a higher risk for food insecurity and its adverse health effects. It is possible this effect may not be seen in more condensed or heavily populated communities.

Overall, our findings underscore the importance of increasing awareness of food insecurity and its associated risk factors within orthopedic trauma patients. The next and perhaps more important step is to identify upstream interventions to address this apparently common issue. Studies assessing such interventions appear to favor public policy initiatives over community-based programs like food pantries. Where social assistance and education programs have been associated with a decrease in food insecurity rates,^30-33 food pantries have demonstrated mixed results and may face other challenges including a reliance on donations, social stigmas, and difficulty providing healthy, nutritious food.^34-38 More investigation is needed to better identify ways to reduce food insecurity in the community.

Beyond directly addressing food insecurity, targeted nutrition supplementation could also play a role in mitigating the adverse effects of food insecurity. Prior studies have suggested that conditionally-essential amino acid supplementation can reduce complications and the rate of muscle loss in the early recovery phase after trauma.^39,40 Whether it be through social programs, targeted supplementation, or other methods, optimizing nutrition in orthopedic trauma patients at risk for food insecurity has the potential to significantly improve their clinical outcomes. Future work should focus on nutrition supplementation as an intervention to reduce complications and functional muscle loss during the healing phase after trauma.

Limitations

This study was performed at a single Midwest institution and our enrollees were homogenous with greater than 90% identifying as non-Hispanic White. Such a cohort does not accurately represent orthopedic trauma patients across the country which limits the generalizability of our findings. Future investigations should include multiple centers in different regions of the country to increase the diversity of the study population. This multicenter design will more accurately estimate the true prevalence of food insecurity in orthopedic trauma patients, better determine its risk factors, and improve the overall generalizability of the results.

Another limitation is although some patients were approached in the inpatient setting, most enrollments occurred in the outpatient clinics. This could introduce selection bias as individuals who are of lower socioeconomic status and potentially higher risk for food insecurity may not be able to reliably attend scheduled clinic follow-up visits. As such, it is possible we have underestimated the commonality of food insecurity at our institution. This may also impact the associations seen between food insecurity and the potential risk factors included in our study.

Finally, although food insecurity has been shown to adversely affect outcomes in prior studies, the cross-sectional design of our study limits any assessments of patient outcomes. We did incorporate into our surveys the number of surgeries needed to treat each patient’s injury in hopes of identifying a relationship between FI and injury severity. This metric did not reach statistical significance. As such, the present data allow us to say that food insecurity is common in our rural orthopedic trauma population but we cannot speak to its clinical relevance in this cohort. We feel the questions of clinical relevance and potential interventions can be addressed in future investigations and that our data will serve as a basis for such studies going forward.

Conclusion

Food insecurity is common in the musculoskeletal trauma population. Those with lower household income and those living alone are more likely to experience food insecurity. Time spent traveling to full-service grocery store was strongly associated with food insecurity. Multicenter studies are warranted to evaluate the incidence and risk factors for food insecurity in a diverse population of trauma patients. Our findings indicate a need for public health initiatives to improve food security in high-risk populations and highlight the potential benefits of providing nutrition supplementation to musculoskeletal trauma patients to improve outcomes.