Original research

Doctors have an ethical obligation to ask patients

J Med Ethics: first published as 10.1136/medethics-2021-107409 on 14 July 2021. Downloaded from http://jme.bmj.com/ on April 21, 2023 by guest. Protected by copyright.
about food insecurity: what is stopping us?
Jessica Kate Knight ‍ ‍ ,1 Zoe Fritz ‍ ‍ 2,3
1
Department of Acute Medicine, ABSTRACT finally address some of the ethical counterargu-
School of Clinical Medicine, Inadequate diet is the leading risk factor for morbidity ments to doing so.
University of Cambridge,
Cambridge, UK and mortality worldwide. However, approaches to
2
Department of Acute Medicine, identifying inadequate diets in clinical practice remain Diet and health
The Healthcare Improvement inconsistent, and dietary interventions (on both The health effects of dietary risks are medi-
Studies Institute, Cambridge, UKindividual and public health policy levels) frequently
3
Cambridge University ated by multiple intersecting causal pathways,
Hospitals NHS Foundation Trust,
focus on facilitating ’healthy choices’, with limited including those associated with ‘overnutrition’
Cambridge, UK emphasis on structural constraints. We examine the and atherogenic diets, as well as those related
ethical implications of introducing a routine question to underconsumption of key micronutrients and
Correspondence to in the medical history about ability to access food. Not macronutrients. Although a large proportion of
Dr Zoe Fritz, The Healthcare collecting data on food security means that clinicians are policy and public attention is paid to the effects
Improvement Studies Institute, unable to identify people who may benefit from support
Cambridge, Cambridgeshire, UK; of excess sugar, salt and saturated fat, the leading
​zbmf2@​cam.a​ c.​uk on an individual level, unable to consider relevant dietary dietary risk factors for mortality (other than a
risk factors for disease and disease progression and high-­sodium diet) are diets low in whole grains,
Received 15 March 2021 unable to monitor population trends and inequalities fruit, nuts and seeds, vegetables and omega-­3 fatty
Accepted 28 May 2021 in dietary access in order to design effective policy acids.1 Crucially, harmful underconsumption and
Published Online First
14 July 2021
interventions. We argue that the current lack of routine overconsumption can co-­ exist, resulting in the
screening for food insecurity is inconsistent with our so-­called ‘double burden of malnutrition’, where
approach to other health behaviours (eg, smoking populations are simultaneously affected by micro-
and alcohol use), as well as with doctors’ frequent nutrient deficiencies, underweight and childhood
informal role as gatekeepers to the food aid system, and stunting as well as overweight, obesity, and related
recent calls for governmental action on food insecurity non-­communicable diseases.3
and health inequalities from individual clinicians and
professional bodies. Potential ethical barriers to asking
patients about food security are addressed, including Hunger, malnutrition and ‘food insecurity’
concerns about stigma, limiting autonomy, fair resource ‘Food insecurity’, or ‘food poverty’, has been
allocation, unclear professional remits and clinicians’ defined as the inability to consume an adequate
ability to offer effective interventions. We suggest that quality or quantity of food in socially acceptable
there is an ethical imperative for doctors to ask patients ways or the uncertainty that one will be able to
about their ability to access healthy food. Gathering this do so.4 The term has been criticised as simultane-
data provides a valuable first step in re-­framing the social ously too specific, in narrowly focusing on food
determinants of health as modifiable risks, rather than without acknowledging the other, broader impli-
inevitable inequities. cations and causes of poverty; and not specific
enough, in avoiding the reality that an ‘insecure’
ability to access food frequently simply leads to
hunger.5 6 However, the concept of ‘food insecu-
INTRODUCTION rity’ remains useful, in that it captures the exis-
No one disputes the relationship between diet and tence of external dimensions (including poverty,
health: our bodies reflect what we eat, and—just as isolation, and mental or physical ill-­health), which
importantly—what we do not or cannot eat. Inad- constrain access to a good diet. Food insecurity is
equate diet is the leading risk factor for morbidity distinct from (though may contribute to) malnu-
and mortality globally, responsible for 11 million trition, which may be related to disease as well as
deaths in 2017, and surpassing the effects of other inadequate oral intake, and is frequently treated
behavioural risk factors including tobacco use, by medical professionals.
alcohol consumption, recreational drug use and Food insecurity in the UK has been a focus of
unsafe sex combined.1 Improvements in diet have growing public attention over the past decade,
the potential to prevent one in five deaths world- particularly with the rise in the numbers and visi-
wide.1 In the UK, patterns are similar, with 10.8% bility of ‘food banks’, third-­sector organisations
of DALYs (Disability-­adjusted Life Years) attribut- providing food to those in acute need. The Trus-
© Author(s) (or their able to suboptimal diet.2 And yet asking about diet sell Trust network, which accounts for around
employer(s)) 2022. Re-­use is not routinely part of the medical history, unlike 60% of UK food banks, report a tripling of their
permitted under CC BY.
Published by BMJ. questions about other determinants of health such food parcel provision in the decade since 2010,
as smoking and alcohol. Here, we first examine the and numbers of independent food banks (unaffili-
To cite: Knight JK, Fritz Z. interrelationship between diet, health and health- ated with the Trussell Trust) have increased corre-
J Med Ethics
2022;48:707–711.
care delivery; then explore whether there is an spondingly.5 7 Further increases in food bank use
ethical obligation to ask about food insecurity, and have been reported as a result of the coronavirus
Knight JK, Fritz Z. J Med Ethics 2022;48:707–711. doi:10.1136/medethics-2021-107409    707
 Original research
pandemic, accompanied by a series of calls, led by Marcus recommend universal screening with the Hunger Vital Sign, a

J Med Ethics: first published as 10.1136/medethics-2021-107409 on 14 July 2021. Downloaded from http://jme.bmj.com/ on April 21, 2023 by guest. Protected by copyright.
Rashford, for governmental action on child food poverty and two-­question tool to identify food insecurity.24–26
‘holiday hunger’.8
The relationship between food insecurity and poor health is
mediated through multiple mechanisms, including constrained IS THERE AN ETHICAL OBLIGATION TO ASK ABOUT FOOD
dietary options (due to cost and the food bank ‘surplus’ supply INSECURITY?
model), compensatory strategies (such as skipping meals or Biological and ethical rationale for asking during initial
relying on energy-­dense foods), inability to control diet in diagnosis
chronic disease (eg, worse diabetes control) and the chronic A primary purpose of the medical history is for the clinician to
stress of not knowing whether there will be enough to eat.5 9–13 gather relevant information required to construct a differential
In 2014, the Faculty of Public Health called on the government diagnosis and create a shared plan for care. Diet broadly, and
to take action on food insecurity by reversing the rising costs food insecurity in particular, are of sufficient relevance to disease
of healthy foods and falls in wages and welfare payments.14 (equivalent to smoking and alcohol histories) to merit routine
More recently, the RCPCH and the BMA issued public state- inclusion in the social history, particularly since malnutrition is
ments in 2020 calling for half-­term provision of free school both common among people presenting to acute services and
meals on health grounds.15 16 has a significant influence on morbidity, mortality and recovery
of functional status.27 Briefly, routine enquiries about access to a
healthy diet could then be followed up, where appropriate, with
Doctors and (non-dietary) health behaviours a more detailed history based on the clinical picture.
A classic dilemma in public health ethics concerns the roles of Some specific diagnoses that could be ascertained through
the doctor and the state in changing health behaviours and the dietary history include the following:
extent to which it is acceptable to restrict the autonomy of an 1. Micronutrient deficiencies, electrolyte imbalances or refeed-
individual or population for the sake of their own or others’ ing syndrome—this can be caused by a restricted diet, due to
health. physical, financial or psychological inability to access varied
Broadly, existing interventions can be divided into those foods, or to voluntary restriction (eg, veganism).28
supporting an individual to change their behaviour (eg, smoking 2. Protein–calorie malnutrition—this can be caused by inade-
cessation services, weight loss programmes) and those altering quate oral intake, particularly in older people with low in-
the behaviour of a population via ‘nudges’ or financial incen- comes, in addition to more commonly treated ‘biological’
tives/disincentives (eg, taxation on tobacco, alcohol or sugar).17 causes such as malabsorption or cachexia.29
In the latter case, the potentially coercive or paternalistic policy 3. Type 2 diabetes mellitus—food insecurity is independently
is frequently justified by its overall positive impact on health and associated with an increased risk of developing type 2 dia-
health equity, as ‘unhealthy’ behaviours are more common in betes.30
people living on low incomes.18 4. Poor medication adherence or efficacy as an explanation for
Certain health behaviours are routinely screened for in both ongoing symptoms—food insecurity has been linked to re-
primary and secondary care. Medical students are taught to duced adherence to medications that must be taken at spe-
enquire about patients’ smoking status and use of alcohol and cific times, reduced maintenance of therapeutic drug levels
recreational drugs as part of the ‘social history’.19 Justifica- and worse disease control, for example, in HIV antiretroviral
tions for this include the relevance of behaviours to diagnostic therapy.31
reasoning, as well as the ability to offer appropriate preven- In addition to providing information relevant to diagnosis and
tative healthcare alongside acute treatment. All NHS-­ funded acute management, a person’s social situation frequently informs
providers are mandated in the NHS Standard Contract to screen safe discharge planning in inpatient settings and referrals to social
for smoking and alcohol consumption, provide brief advice and care by GPs. Doctors are comfortable routinely asking about this
offer referral to specialised services. This is justified because it (marital history, help at home, etc). Ability to access food is ethi-
may ‘reduce the burden on the NHS, premature mortality and cally equivalent in terms of balancing perceived infringement of
morbidity (and) health inequalities’.20 Implementation of the privacy (‘why do you want to know what I have in my fridge?
‘Ottawa Model’ for smoking cessation, in which smoking status What does it matter to you who I live with?’) with achieving
is identified and documented for all inpatients, and intervention good health outcomes: an empty fridge has shown to be a signif-
and follow-­up are provided, is known to significantly increase icant predictor of early readmission among older adults.32
cessation rates 6 months post-­discharge.21 A dietary history is relevant across the full range of clinical
environments: in secondary care, doctors’ awareness of dietary
Doctors and dietary health behaviours challenges may inform their initial diagnosis, referral for dietetic
There is no specific UK guidance recommending that clini- support within hospital and plans for discharge. Meanwhile in
cians routinely ask patients about their dietary habits or about primary care, clinicians may better placed to offer brief advice,
barriers to accessing a ‘healthy’ diet; NICE’s recommendations referral or signposting to local support groups and services on
are based on encouraging a balanced diet and screening for a longer-­term basis, integrated with a biopsychosocial model of
malnutrition.22 23 In the USA, where food insecurity has been medical care. In the face of clear evidence concerning the impact
annually monitored through the National Food Security Survey of food insecurity on health outcomes, it is ethically inconsistent
since 1990, there have been calls to integrate routine screening to avoid discussing factors affecting access to a good diet in clin-
of diet and food insecurity into clinical practice. The American ical settings.
Heart Association argue that health impacts of poor diet and the
potential for healthcare cost reduction provide a strong rationale Integrating dietary support with management of long-term
for the implementation of a universal dietary screening tool in conditions
the electronic health record, while both the American Academy Introduction of routine screening for food insecurity has the
of Paediatrics and the American Association of Family Physicians potential to allow patients and clinicians to create more effective
708 Knight JK, Fritz Z. J Med Ethics 2022;48:707–711. doi:10.1136/medethics-2021-107409
 Original research
shared plans for dietary management of long-­term conditions be an influential tool in displaying the efficacy or otherwise of

J Med Ethics: first published as 10.1136/medethics-2021-107409 on 14 July 2021. Downloaded from http://jme.bmj.com/ on April 21, 2023 by guest. Protected by copyright.
and to minimise shame felt by some people experiencing food current systems and in advocating for change when needed.
insecurity when given inappropriate ‘lifestyle advice’. These feel-
ings appear to be prevalent: participants in a study in north east Improving clinical practice
Scotland believed that their GP was unaware of their struggle to Doctors have a primary duty to improve clinical practice and to
afford food and expressed reluctance to spontaneously confide ensure that their care is reflective of both progress in biomed-
in healthcare professionals, due to concerns over wasting clini- ical research and the changing needs of the people they serve.
cians’ time, embarrassing them or their inability to help.12 A Although food insecurity in the UK is not a new problem, the
related study of healthcare professionals found mixed aware- high profile of the issue in recent months provides a crucial
ness of the issue, though some practitioners specified occasions opportunity to make changes which ensure that healthcare
when their patients’ illnesses had been specifically worsened by services adequately meet the needs of food-­insecure patients and
their food insecurity (eg, inability to maintain a high-­calorie diet reflect the clear consensus that there can be no place for hunger
in COPD (Chronic Obstructive Pulmonary Disease), or a low-­ within a just society.
carbohydrate diet in diabetes.)11 There are frequent public calls for governmental action on
Long-­term conditions are common in those with food insecu- food insecurity by medical professional bodies,15 16 but as well
rity: nearly 75% of people who have used a Trussell Trust food as this vital broader policy change, it is important that these are
bank have at least one such disease,5 and evidence suggests that also accompanied by change within healthcare services. The
experience of food insecurity undermines people’s ability to medical history provides a powerful tool for shaping individual
manage their long-­term conditions,5 12 33 34 including skipping attitudes and institutional cultures: Moscrop et al39 argue that
meals and cutting back on medication.12 Those living with both by remaining effectually ‘blind’ to social determinants of health
diabetes and food insecurity, for example, have worse glycaemic (even those, like food insecurity, which are relatively down-
control than those without food insecurity; 30 the control is stream), ‘doctors help to conceal these problems from public
improved on receipt of adequate aid.35 view and from the political agenda… Ending the complicity of
Discussion of food insecurity need not be confined to conver- the medical profession in health and healthcare inequities begins
sations about a modifiable risk after risk-­ related conditions with data gathering’.”
have arisen: primary as well as secondary prevention should be Routinely recording people’s ability to access the food they
encouraged. Routine dietary screening, particularly in primary need, rather than simply providing advice on ‘healthy choices’,
care, provides the option of offering support and signposting to provides one small step to creating a healthcare system which
anybody at risk of experiencing food insecurity and interrupting truly promotes equal access to health for all.
the cyclical relationship between poor dietary access and devel-
opment of disease.24
ADDRESSING THE COUNTERARGUMENTS: POTENTIAL ETHICAL
BARRIERS TO ASKING ABOUT FOOD INSECURITY
Designing effective support systems Stigma and trust
Health and social care professionals, including doctors, One prominent concern about introducing questions about food
currently act as gatekeepers to the UK’s rapidly growing food aid security into healthcare settings is the potential of damaging the
system34—over 60% of independent food banks require refer- therapeutic relationship by eliciting shame and perpetuating self-­
rals from a third party.7 Despite this, food banks are commonly blaming stigmas associated with being unable to reliably access
funded entirely by charitable grants and public donations and food. Poverty itself may be experienced as shameful,40 and
run by volunteer labour.33 34 There is also interprofessional vari- food aid is frequently positioned as an act of ‘charity’ rather
ability in knowledge of local food aid services and frequency of than fulfilment of a basic right, invoking an idea of ‘compulsory
referral.11 Given the inconsistent and informal organisation of gratitude’ and a lack of self-­determination, which can lead to
current systems, doctors’ and patients’ frequent sense of help- humiliation.41
lessness in the face of food insecurity is perhaps unsurprising. However, advocates of a ‘public health approach’ to issues
Significant gaps also remain in current approaches to measuring such as knife crime or substance use contend that treating some-
the prevalence of food insecurity on local and regional levels in thing as a health concern, not an individual failing, can help
the UK and in the ability of existing data to link experience of to promote support rather than stigmatisation.42 Though not
food insecurity to specific health outcomes.36 37 Monitoring in directly analogous, framing access to food in terms of health
healthcare settings has the potential to meet this unmet need, and the right to a good diet, rather than relegating responses to
informing epidemiological research as well as local authority ‘charity and chance’, may have a similar effect.4
or CCG funding and policy decisions; for example, by explicit Healthcare professionals are used to discussing difficult issues:
inclusion of food insecurity data into Health (or Health Equity) pain, dying, continence, sexual problems and psychological
Impact Assessments. trauma are part of everyday medical and nursing practice. Future
The current informal referral ‘system’ risks both missing clinicians receive communication skills training allowing them
opportunities to provide effective support and passively insti- to discuss these issues with sensitivity, empathy and an atten-
tutionalising food banks as a permanent part of the UK welfare tion to power imbalances in therapeutic relationships. There is
support infrastructure. Explicitly acknowledging the extent of no reason why it should be impossible to create the necessary
reliance of healthcare providers and other statutory services training to enable food security and income to be discussed
on charitable food aid organisations would instead promote with equivalent care and dignity, minimising the provocation of
working in partnership to design evidence-­based improvements shame.
in support services—for example, many food bank providers
and anti-­poverty campaigners push for a ‘Cash First’ approach, Respecting autonomy
ensuring people receive adequate financial assistance rather than Asking people about their ability to access food or signposting
emergency food.38 Data collected in healthcare settings may to sources of support with food or finances may potentially
Knight JK, Fritz Z. J Med Ethics 2022;48:707–711. doi:10.1136/medethics-2021-107409 709
 Original research
be seen as an intrusion into a person’s freedom to direct their ► Openness means that decision-­making should be transparent,

J Med Ethics: first published as 10.1136/medethics-2021-107409 on 14 July 2021. Downloaded from http://jme.bmj.com/ on April 21, 2023 by guest. Protected by copyright.
own life. and the ethical basis for allocation of resources accountable
Similar concerns may be raised about many measures to to the public. The normative basis for current allocation of
address ‘lifestyle diseases’ in medical practice. Advice about healthcare funds to dietary health promotion initiatives must
healthy habits and ‘disincentive’ policies to change population therefore be explicit.
behaviour, such as the sugar tax, inevitably restrict individual The philosophical justification for improving knowledge
liberty and may be seen as paternalistic. It has been argued that about food access, as well as access to food, is therefore robust.
if lifestyle-­induced ill health is due to a poverty of options, it is Whether this falls into the remit of healthcare professionals is
counterintuitive to further restrict limited options with ‘disin- another question hat needs addressing.
centive’ policies, which inevitably have the greatest impact on
people with the least (economic) ability to choose.18 Professional and policy remits
There are, however, existing intrinsic constraints on people’s Further integration of food aid into healthcare could be argued
ability to choose at food banks, and no unified ethical basis to shift institutional responsibility for hunger to healthcare
for good practice which ensures respect for autonomy in food professionals and distract from the responsibilities of poli-
aid services, though frameworks based on the ‘social empathy’ ticians and welfare and economic policy reform. However,
model and ‘capability approach’ have been proposed.43 ‘Means healthcare professionals (especially GPs) already give advice
paternalists’ argue that we should accept people’s goals and about diet, gatekeep entry into the food aid system and treat
aim at steering (or nudging) people’s behaviour towards those the eventual consequences of diet-­induced or diet-­exacerbated
goals17—and in doing so increase their long-­term ability to make disease. Explicitly integrating assessment of food insecurity
autonomous choices. Formalising existing informal systems of into healthcare, and documenting the extent of this reliance
referral from healthcare professionals (who have an explicit duty on voluntary organisations, may act to further incentivise
to protect autonomy) into food aid services may therefore act to development of effective policy responses to upstream causes
promote, rather than limit, freedom of choice. such as income inequality, and help monitor health and social
care costs (or benefits) of policy changes.

Justice and resource allocation

Ability to intervene
Introduction of questions about food security into routine
It is evident that existing interventions to address food insecurity
practice involves a use of healthcare resources, both in terms
are not always working,47–49 so it is reasonable to be concerned
of the already stretched time of individual clinicians and the
about the ethical implications of ‘screening’ for a condition that
financial implications of any further programmes implemented
does not currently have an effective ‘cure’. Doctors may feel
as a result of data gathering. It is therefore reasonable to ques-
impotent to deal with food insecurity, even if they are empow-
tion whether this would be a just use of limited resources avail-
ered to unearth it. Increased education about doctors’ potential
able within the healthcare system. Fritz and Cox44 propose a
role as gatekeepers into the food aid system may be a short-­term
framework with which to ensure that conflicting needs are
solution.50 Longer term, gathering data about food insecurity
considered fairly using an application of Rawlsian principles
may incentivise the development of effective, evidence-­ based
including equity of access, openness, just savings and the differ-
support structures and equitable, evidence-­based policies.
ence principle, to ensure that justice is embedded in the health-
care system.
These principles may be applied to demonstrate that further CONCLUSIONS
allocation of healthcare resources towards routinely asking There is a clear unmet need for further evidence and profes-
about diet and improving dietary access would be a just use: sional guidance concerning the monitoring and treatment of
► The difference principle states that primary goods should food insecurity within healthcare settings. Current approaches
be distributed equally unless an unequal distribution would to food insecurity are inconsistent, both with treatment of
make the least advantaged in society materially better off other health behaviours such as alcohol and smoking and with
than they would be under strict equality.45 The (physical recent public statements by professional bodies calling for
and financial) ability to follow dietary advice is currently action to end food poverty. Routine recording of the prev-
distributed unequally, restricting the ability of many to act alence and implications of food insecurity within healthcare
as ‘normal and fully cooperating members of society over settings may both allow better care for individual patients and
a complete life’.46 Physicians’ time spent in routinely elic- also provide evidence to facilitate effective policy interven-
iting a dietary history—which would take longer for some tions to end hunger, both within and external to the health-
patients than others—would be justified in increasing the care system. Gathering this data provides a valuable first step
opportunities for those who were least advantaged, both in re-­framing the social determinants of health as modifiable
through individual support, and through the data generated risks rather than inevitable inequities.
to guide policy and interventions.
► The just savings principle promotes intergenerational justice: Twitter Zoe Fritz @drzoefritz
investment in future health via preventative healthcare (such
Contributors JKK and ZBMCF conceived of the idea for the article. JKK conducted
as promoting equal dietary access for all) is reasonable a review of other articles and wrote the first draft. ZBMCF wrote additional sections.
despite a potential opportunity cost at the present. ZBMCF and JKK both contributed to subsequent and final drafts.
► Equity of access is enshrined in the NHS Constitution, yet Funding This study was funded by Wellcome (Grant no. 208213/Z/17/Z); University
there is an emphasis on funding interventions which aim to of Cambridge; Health Foundation.
change individual dietary behaviours in spite of evidence Competing interests JKK is a medical student and one of the directors at Oxford
that dietary access is also constrained; the role of the NHS Mutual Aid, a community support group that provides food parcels and meals to
in ensuring or at least facilitating access to nutritious food people experiencing food insecurity.
deserves further exploration. Patient consent for publication Not required.

710 Knight JK, Fritz Z. J Med Ethics 2022;48:707–711. doi:10.1136/medethics-2021-107409

 Original research
Provenance and peer review Not commissioned; externally peer reviewed. 22 National Institute for Health and Care Excellence. Nutrition support for adults: oral
nutrition support, enteral tube feeding and parenteral nutrition (NICE guideline CG32.

J Med Ethics: first published as 10.1136/medethics-2021-107409 on 14 July 2021. Downloaded from http://jme.bmj.com/ on April 21, 2023 by guest. Protected by copyright.
Data availability statement No data are available. 37, 2017.
Open access This is an open access article distributed in accordance with the 23 National Institute for Health and Care Excellence. Preventing excess weight gain |
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