The Distinct Role of Occupational Therapy in Combating Food Insecurity Among Older Adults

Elena (she/her/hers) is a 74-year-old Latina woman who has been referred to occupational therapy for a decline in performing basic and instrumental activities of daily living (ADLs/IADLs). Elena lives alone in an apartment complex located in a large metropolitan area. She has four children residing in other states who visit her infrequently. Elena lives on a fixed income from her deceased husband's social security.

According to results from the occupational therapy evaluation, Elena's decline in performance is due to an exacerbation of chronic obstructive pulmonary disease (COPD) with severe shortness of breath impacting ADL/IADL performance. The outcome of the Hunger Vital Sign Screen¹ reveals that the food Elena had bought in the last 12 months ran out, and she did not have enough to buy more food. Subsequently, Elena cuts back on her COPD medication to buy food.

Elena is one of 13.8 million U.S. households² suffering from food insecurity. How can we, as occupational therapists, help patients like Elena?

What Is Food Insecurity?

The U.S. Department of Agriculture defines food insecurity as "a lack of access to enough food for an active, healthy life.³ There are four levels of food security:⁴

• High Food Security: Individuals can consistently access nutritious food.

• Marginal Food Security: Although individuals can access nutritional food, they experience persistent anxiety about affordability and obtaining more.

• Low Food Security: Individuals can only access food with minimal to no nutritional value.

• Very Low Food Security: Individuals have no consistent access to any food and must frequently skip meals. Older adults at this level face an increased risk of hunger.

Populations at Higher Risk for Food Insecurity

Although experiencing food insecurity can happen to anyone, certain populations are at higher risk, including those who:⁵

• Have an income below the poverty line

• Are single mothers

• Possess a lower level of education

• Identify as Black, African-American, or Latinx

• Are separated, divorced, or never married

• Live in rural areas

• Identify as disabled

• Are over the age of 62 and living alone

• Rent vs. own their homes

Additional factors contributing to food insecurity include:³

• Lack of affordable housing

• Living in areas with limited access to nutritional food (also known as food deserts)

• Restricted home accessibility

• Racism

• Lack of access to transportation

• Social isolation

• High medical costs

• Low wages

• Being unable to work full-time or qualify for Medicare or Social Security between 50 to 64 years of age

The Health Effects of Food Insecurity on Seniors

Approximately 5.2 million (7.1 percent) of older Americans experienced food insecurity in 2019.⁶ Since the COVID-19 pandemic, this number has increased. Furthermore, older adults with functional limitations are at greater risk of food insecurity. Among this population, malnutrition is a serious issue leading to loss of appetite, difficulties with chewing and swallowing, adhering to medication regimes, functional and cognitive decline, and gastrointestinal problems. Food insecure older adults are more prone to suffer from high blood pressure, congestive heart failure, diabetes, and experience heart attacks. Food insecurity also increases the risk of falls resulting in non-fatal and fatal injuries.⁵

Food insecure adults may utilize coping strategies that inevitably result in behaviors that harm their health. These include cutting back on medication, not taking medication with food, postponing preventative or necessary medical care, consuming diets of low nutrient value, and making trade-offs between food and other necessities. In addition to harmful coping behaviors, food insecurity can exacerbate existing conditions, including poor glycemic control and end-stage renal disease, and lower immune system health.⁵

The Distinct Role of Occupational Therapy in Addressing Food Insecurity

Occupational therapy practitioners providing services to community-dwelling older adults are in an optimal position to incorporate basic food screenings and assessments into their practice to identify individuals at risk of food insecurity and challenges through food-related activities.⁷ When occupational therapists understand the complexity of food insecurity, they can address its many dimensions in a client-centered context. Older adults may encounter numerous natural and built barriers, including home accessibility, inclement weather, and neighborhood accessibility, which all affect their ability to leave home.

For example, Elena's OT administered the Hunger Vital Sign screen, a validated and quick two-question screening tool to identify the risk of food insecurity.⁸ The U.S. Household Food Security Survey Module (HSFFM): Six Item Short Form is valuable for identifying the four levels of food insecurity. The HSFFM is within the scope of occupational therapy practice in identifying food insecurity.⁷ The client-centered Occupational Performance Measure of Food Activities (OPMF)⁹ is a 15-item scale that helps OTs obtain information regarding perceived satisfaction, performance level, and satisfaction related to shopping, cooking, eating, dining out, and healthy eating.

During their sessions, Elena's OT addresses other food-related activities, including:

• Home modifications: installing railings for entering/exiting the home

• Education in food safety practices¹⁰

• Assessment of self-feeding and oral-motor skills, including chewing and swallowing

• Kitchen adaptations: lighting, adjusting cookware for reach at shoulder or waist height, adaptive equipment, and devices

• Simplifying meal preparation: energy conservation techniques, less complex recipes, preparing one-pot meals, and using pre-prepared ingredients

• Nutrition literacy

• Meal planning and budgeting for nutritious meals

• Incorporating cultural preferences related to meal preparation

Elena's OT collaborates with social workers to assist her client in accessing community resources such as:

• In-home meal delivery, such as Meals-on-Wheels

• Alternative transportation services for shopping

• Food banks

• Enrollment in the Supplemental Nutrition Assistance Program (SNAP)

• Congregate dining services, such as churches as well as senior and recreational centers

• Community and neighborhood gardens

• Food-rescue organizations

• Senior Farmers' Market Nutrition Program

The prevalence of food insecurity among older adults is a growing public health and occupational justice issue. Inadequate nutrition exacerbates and contributes to chronic illness. With increased awareness of older adults' risks for food insecurity, OTs possess the tools and skills to mitigate the risks and ensure participation in essential occupations.