How do patients with IBD face food insecurity in general?

Yuliya Rekhtmann, MD, mentions "Lack of knowledge on nutrition in general. Lack of available professional resources. Lack of interest. These are [the] 3 most common things I see in my practice."
Greta Breskin, MS, RDN, LDN
- Patients on private insurance can face a tougher time paying for out-of-pocket expenses for formula as part of Exclusive Enteral Nutrition Therapy.
- Families with tougher financial situations will prioritize children's food costs with IBD as opposed to own food.
- Financially insecure families have tougher challenges with restrictive diets like the SCD diet.
Marc Tsou, MD "Varies with age group, majority in teens...1 in 8 IBD patients face food insecurity [and] patients with food insecurity are 7 times more likely to face financial hardship."
- College student population:
  - College students have a tendency to grab fast and processed foods
  - SCD, Exclusion diets, and EEN are difficult to adhere to in college vs living at home
  - Ostomies make it harder to adhere to proper diet because of restrictions on healthier foods (i.e. raw vegetables)
  - Meal plans can lack options for people with dietary restrictions or are on diets like SCD, CDED, or EEN
- Younger families/kids:
  - Susceptible to social constraints and peer pressure, especially when eating out
  - Parents will have more control/supervision over this population, so they are more aware of pro/anti inflammatory foods, probiotics, and infant formulas with prebiotics

Food Insecurity

Food insecurity can be broadly defined as the inaccessibility to adequate nutrition because of many factors such as financial situation, environment, and chronic illness. The connection between chronic illness and food insecurity is something that is understudied. We hope to spread awareness on the connection between the two, so we reached out to various providers regarding this.

How has COVID-19 impacted those with IBD who are facing food insecurity?

Dr. Yuliya Rekhtmann, MD, says "[There has been a general] fear to go out to the store[s]."
Greta Breskin, MS, RDN, LDN predicts that the proportion of patients with IBD in general has increased due to financial hardship and stress for families
Dr. Marc Tsou, MD says that there is a concern with infection risk, but SECURE-IBD shows patients are generally not at higher risk of contracting COVID-19.

What are helpful resources for those with IBD who face food security?

Dr. Yuliya Rekhtmann, MD, says,"Dietician is imperative. Educational material on not only on what NOT to eat, but about what TO eat, that are easy to read and give common sources of nutrition. Families are cooking more, so maybe adding some easy recipes that do not break the bank."
Greta Breskin, MS, RDN, LDN, suggests using the ChooseMyPlate.gov website for healthy eating on a budget
Breskin additionally suggests for those who have dietary restrictions, such as a gluten-free diet, because gluten-free foods are specialty foods, a cost-friendly alternative would be to try to find more natural alternatives.
- For example: Instead of a certain brand of waffles or bread, opt for gluten free natural product like brown rice or gluten free oats.

Yuliya Rekhtmann, MD, says,"I tried not to alter my therapies too much if patient has medical insurance. We have an ability to get SW [Social Work] involved pretty fast to help. Given my specific population ( underserved and poor) I tried to make sure my kids get disability [aid] and medicaid as soon as they are eligible."
Greta Breskin, MS, RDN, LDN, says "Huge factor into whether you would do a diet therapy"
Breskin notes that they would be hesitant to do diet therapy unless they're doing EEN and have Medicaid
Breskin also notes that socioeconomic status, food insecurity, and who has access to diet therapy are all very important to understand
Time and cooking ability influences budget for families as cost-effectiveness increases with more time for preparation
Marc Tsou, MD notes that this is one factor in the process
- Can consider alternatives to pills because we can now combine diet and non-diet therapies
- Can combine immunomodulators with dietary plans as necessary

How does food insecurity factor into the decision making process with regards to treatment plans?

What do you think would be important to include about food insecurity and IBD?

Yuliya Rekhtmann, MD, suggests,"That cooking is cheaper then buying premade meals. Asking kids to be involved in the kitchen, so they choose what they eat."
Greta Breskin, MS, RDN, LDN suggests:
- Providers shouldn't be afraid to ask if/how financial stress is affecting families of those with IBD
- Families, if the provider makes an unfeasible suggestion, to not be afraid to bring up the financial challenges
- Obtaining more resources from psychosocial professionals
- Telehealth visits have been particularly helpful because calls are often made from kitchens, patients/families are more comfortable at home and can hold longer conversations, and most patients at their center have longer drives
Marc Tsou, MD suggests:
- Transition process: there are increasing responsibilities with IBD management beyond copay, food, driving to appointments, etc.
- Nutrition and diet therapy: Not every IBD care center has a dietician
- Getting input from parents and patients from different age groups as there are unique challenges in each age group with nutritional approaches

Two Question Hunger Screen

If patients or families of patients answer that at least one of the following two statements is sometimes true, their household could be at risk for food insecurity

“ Within the past 12 months we worried whether our food would run out before we got money to buy more.”
“ Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”

Sources: Greta Breskin, MS, RDN, LDN, Hunger Vital Sign

In Collaboration with Yuliya Rekhtmann, MD, Georgetown University Medical Center, Greta Breskin, MS, RDN, LDN, University of North Carolina, and Marc Tsou, MD, Children's Hospital of The King's Daughters