Did you know that more than 1 in 5 children with food allergies also experience food insecurity (FI)? Children whose families struggle to acquire adequate nutrition are at higher risk for a wide range of conditions, including asthma, obesity and mental health issues.
In this podcast, you’ll hear more on this topic, including guidance on FI screening in the pediatric care setting, from Jodi Shroba, MSN, APRN, CPNP, Food Allergy Program Coordinator for the Division of Allergy, Immunology, Pulmonary and Sleep Medicine at Children’s Mercy Kansas City.
Selected Podcast
Food Insecurity Screening in the Allergy Specialty
Featured Speaker:
Jodi Shroba, MSN, APRN, CPNP
Jodi Shroba, MSN, APRN, CPNP is the Food Allergy Program Coordinator for the Division of Allergy, Immunology, Pulmonary and Sleep Medicine at Children’s Mercy Kansas City. Transcription:
Food Insecurity Screening in the Allergy Specialty
Dr Andrew Wilner (Host): Thank you for joining me for another episode of Pediatrics in Practice with Children's Mercy Kansas City. I'm your host, Dr. Andrew Wilner, Associate Professor of Neurology at the University of Tennessee Health Science Center and Division Director of Neurology at Regional One Health Memphis, Tennessee.
My guest today is Jodi Shroba, pediatric nurse practitioner and Food Allergy Program Coordinator in the Department of Allergy, Asthma and Immunology at Children's Mercy Kansas City. She also heads the American Academy of Allergy, Asthma and Immunology Food Insecurity Work Group.
At Children's Mercy, Jodi serves on the Hunger-Free Hospital Council and the Medical Advisory Board of the Food Equality Initiative. Today, she will enlighten us about the problem of food insecurity and food allergies in the pediatric population. Welcome, Jodi Shroba.
Jodi Shroba: Thank you. I'm so excited to be here today. And food allergy is one of my main focuses at work. And, obviously, the pandemic has brought food insecurity to light. So this is a good way to bring the two things together and talk about them as they do go hand in hand.
Dr Andrew Wilner (Host): When I was in medical school, I don't remember the term food insecurity. It seems to be sort of a new phrase. Could you define that for us?
Jodi Shroba: Sure. I feel like when I was in my grad school program, we didn't talk much about food insecurity either. So, I do feel like it's maybe one of those more buzzwords that you hear a lot more of today, same thing as shared decision-making is another one of those kind of buzzwords. But the definition of food insecurity is really the inability to provide enough safe nutritious food to meet your dietary requirements for people. And then, there's also the term very low food insecurity, which means that not only are you food insecure, but you're actually are adjusting your eating patterns because you do not have enough food to even provide for an adequate nutritional level.
Dr Andrew Wilner (Host): You know, this is the United States of America. Is this a problem?
Jodi Shroba: Sadly to say, yes. You would think we're the big, bad mighty United States and, sure, we have enough food for everybody to go around, but, sadly, that is not true. Some frightening statistics. In 2020, about 10% of US households were considered food insecure. So if you want to put that into numbers, that's 13.8 million people declared food insecurity in 2020. Those that were very low food insecure in 2020 we're about 3.9%, so about 5 million. While we do not have official numbers for 2021 yet, the projected model with the COVID pandemic is going to bump those numbers up to about 13% are food insecure. So again, 42 million people in this country report not having enough food to eat. And what really makes that sad is to think that 6.8% of these households have children that are reporting food insecurity.
Dr Andrew Wilner (Host): Sure. And, you know, it's important obviously for children to have proper nutrition for -- Well, I'm a neurologist -- for brain growth, for one thing, as well as a proper development in every way. And then on top of that, there's this problem of food allergies. The famous one, I guess, is peanuts. I remember I was on an airplane actually and a young child got ahold of the free peanuts. And luckily, the mother had the EpiPen, but it was quite a drama. How common is that?
Jodi Shroba: Well, the problem on the planes is actually is not common anymore since they have removed peanuts from airplanes. But in the United States, 32 million Americans have a food allergy. And of that, about 8% of children have a food allergy. So, again, throwing out percentages is sometimes hard for people to wrap their head around.
So if you want to think of a classroom of, say, 25 kids, two kids in every classroom are going to have a food allergy. And we do know that there are the top nine big food allergies. We used to say the top eight and sesame's getting added to that list. So the most common food allergies are peanuts, tree nuts, milk, egg, soy, wheat, finfish, shellfish and sesame.
Dr Andrew Wilner (Host): You know, the schools try and provide nutritious meals for children, but I think if they eliminated all of those, there's not much left. No milk, no soy, no nuts. So, do the schools take that into account, as they're trying to feed children healthy meals?
Jodi Shroba: They do. A lot of schools have gone peanut and tree nut-free. But like you mentioned, to have nutritious meals, you can't avoid, egg, milk, soy, wheat. You know, those are the foundations of most foods we eat. So those foods are still available. And part of my job is, not only do I clinically diagnose food allergies, but I have to teach families and children how to live in a world where their food allergy is around them.
If you think about food allergies, for example, I mean, we eat three meals a day, two snacks, maybe three snacks a day. Their main illness is always around them with food. And so we have to teach them how to safely navigate that world. And that's part of my job and that's probably the part of my job I love the most, is the education of how you can live with food allergies. And in part of where the food insecurity and food allergy comes together is because the only management currently for food allergy, because there is no cure, the only management is avoidance. And so for these kids to stay healthy, they need to not eat their allergen.
So then you talk about now you're relying on food assistance, whether it be through the schools or the Summer Meal Programs or WIC or SNAP, which is a supplemental nutrition program, formerly known as Food Stamps, or even food pantries, food banks, they can't accommodate maybe all of these necessities that children with food allergies have. And so they have to just get what they can get and then hand it out to families. And they talked about during the pandemic, you'd see those lines of cars lined up at the food banks and they would just put a box of food in the back of their car. And they didn't ask you, "Oh, do you have any dietary restrictions?" no, you got what you got. And that may be fine for a lot of people, but those with food allergies, they were still maybe not getting the foods that adequately met their nutritional needs. And so that's where that food allergy and food insecurity goes so hand in hand, because the treatment of food allergies is the avoidance of food. So then how do we get them safe food? And then if you don't have the money to afford them, I don't know if you've ever been to the grocery store and looked at the price difference between, say, a loaf of bread and a loaf of bread that does not have wheat in it, and the cost is enormous. If you look at the cost of a jug of milk, which we all know is very expensive. I was just at the store yesterday. I paid $5 for the jug of milk. For those that need to get, say, one of the nut milks or a soy milk, they're going to pay triple, quadruple that amount for a quarter of the amount. And so that's where the real problem comes in, is that the family still may be able to afford food for their children that don't have food allergies, they may not have the money to pay for these specialty foods because they are so expensive.
Dr Andrew Wilner (Host): Does food allergy include gluten intolerance? Does that fall into that category? I know that's very common.
Jodi Shroba: Yeah. So, we could do a whole podcast just on that. You might have to invite me back. So when you talk about a gluten intolerance, that is a problem of the GI system. So the GI system is unable to break down essentially the gluten. And gluten is used in a lot of foods. Primarily, it's used in a lot of our foods in America, at least as a filler and a preservative. And so, there really is not an allergic response to gluten. People that have trouble with wheat, that are allergic to wheat, that's an IgE, so meaning your immune system gets involved; where gluten intolerance is just that your body can't break it down, so it only involves the GI tract; where a food allergy is going to involve your entire immune system.
So there is a very big difference between the two. However, those with a wheat allergy, they will use the gluten-free products because of the fact that wheat and gluten go essentially hand in hand.
Dr Andrew Wilner (Host): Thank you for clarifying that. Now, tell us about your work with the American Academy of Allergy, Asthma and Immunology. I understand you did a survey.
Jodi Shroba: We did. So, probably through most medical specialties, there's always subcommittees of the varying diseases that your specialty treats. And so, we call it Quad AI. That's an easier way to say than American Academy of Allergy Asthma and Immunology. So through the Quad AI, we do have a subcommittee called the Adverse Reactions to Food Committee. And most of the members on there are people that do specialty work, subspecialize in food allergy, management, research. And so, through that subgroup, they kind of break that off and then you kind of have sub subcategories.
And so through the pandemic, we realized that there really wasn't kind of a subcategory to talk about food insecurity and what was being done for it. And I think before the pandemic, maybe all of us had our rose-colored glasses on, that maybe those social determinants of health really aren't a big deal in the specialty world. We knew they existed in primary care and we knew that primary care physicians took care of them. But in the specialty world, we kind of skated over them.
And so with the pandemic and seeing on the news about how people were just unable to get food, it sparked us to say, "Are we looking at food insecurity?" And again, going back to that, our patients, their treatment is avoidance of food. And so if they're insecure, what's going to happen? So we created this work group report and I had allergists on it. I had some psychologists on it. Nurses are on it. We even had some dieticians and then we had a community advocate from a food equality initiative, which is also an organization that helps those that are food insecure that have food allergies and celiac disease. And so we kind of came together as a group and we just said, "Let's talk about it. Let's find out what the allergy community is doing."
Now at the time that we sent the survey, I think there was a lot of maybe some survey fatigue or just people that were just-- you know, COVID was a big deal and people were dealing with a lot of things on top of it, so filling out a survey may have not been their first priority. But of the results that we got back, it was interesting to note that only about 25% of those that responded to the survey are actually screening for food insecurity. And about 70% said they weren't even talking about it with their family. Even if they weren't screening it, they weren't even having a discussion about it.
So we went ahead and created a work group report that we did explain the survey and kind of those results that we had. But then, from the survey, we learned that people didn't know how to screen for it. They didn't have enough information about what resources should you have if you have a family that's food insecure and just really didn't know how to even talk about food insecurity. So we almost kind of turned it into a how-to manual, where we provided varying food insecurity screenings that are available, mainly through our more primary care-based organizations, and then talking about some of those national and federal programs that can help and then maybe how you can start working with some of your local food banks and some of our allergy non-for-profit organizations to really kind of help our families. And just try to make practitioners feel more comfortable, bringing up a situation that is uncomfortable. People are sometimes afraid to admit that they need help. And so we really wanted to make a food insecurity screening feel normal and to feel like just the normal part of an exam, just like a normal part of an exam in every clinic is vital signs. So why not make screening for food insecurity like a vital sign? And that's why we use the hunger vital sign, which is a two-question survey just finding out what their needs are with food.
Dr Andrew Wilner (Host): Right. It's kind of like depression. You know, it's awkward to ask people, "Oh, are you suicidal?" You know, so there's I think a two-question depressions tool that's widely used now. And if you get a positive answer on one of the two, you better ask some more questions and try and help that person. But yeah, these are sensitive topics. Well, are there any important takeaways that you would like pediatricians to know?
Jodi Shroba: I want to always give kudos to our pediatric partners because social determinants of health has been something that's been screened in the primary care clinic, much longer than it's been screened in the specialty clinic. So, they were already doing this movement and now I think the movement is specialty care is going to get more involved with that. So that is my kudos to the primary care providers.
I think it's that we need to recognize that in a lot of diseases, and you being a neurologist, you know, think about your kids with epilepsy and they have special diets that they're on and, here in food allergy, we have kids that avoid food. So they're on special diets. GI providers have special diets based on their diagnosis. We could go down the list, diabetics.
I think that we need to really, as a medical community, start thinking about making food almost like a medicine and that we should be having prescription plans that will allow us as providers to write prescriptions for food and write prescriptions for foods that are necessary based on the diagnosis our patients have.
And so it really should be food is medicine, because food is so imperative to a lot of the diagnoses that we as specialty care take care of. And so I think that us working with our primary care partners, we could really build a big movement and start making some real policy change and some change on our insurance plans that allows us to write for food, because when you get down to the root of all medicine, diet is what keeps everybody healthy. And we need to get back together and work together to make food as acceptable as prescribing a pill.
And I hope that's what primary care providers will get out of today, is that food is so important and we need to all get on board making discussions about food insecurity not an uncomfortable conversation, and then also to come together to try to make food more accessible to all of our patients.
Dr Andrew Wilner (Host): Well, thanks for that. I think you might be onto something there. Jodi, thanks for enlightening us about food insecurity and food allergies in children.
Jodi Shroba: Well, thank you. And again, thank you for having me. And I look forward to seeing all of the medical community come together one day and we don't have to talk about food insecurity.
Dr Andrew Wilner (Host): This has been Pediatrics In Practice with Children's Mercy Kansas City. Please remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. To learn more about nutrition services at Children's Mercy, please visit childrensmercy.org. I'm your host, Dr. Andrew Wilner. Thanks for listening.
Food Insecurity Screening in the Allergy Specialty
Dr Andrew Wilner (Host): Thank you for joining me for another episode of Pediatrics in Practice with Children's Mercy Kansas City. I'm your host, Dr. Andrew Wilner, Associate Professor of Neurology at the University of Tennessee Health Science Center and Division Director of Neurology at Regional One Health Memphis, Tennessee.
My guest today is Jodi Shroba, pediatric nurse practitioner and Food Allergy Program Coordinator in the Department of Allergy, Asthma and Immunology at Children's Mercy Kansas City. She also heads the American Academy of Allergy, Asthma and Immunology Food Insecurity Work Group.
At Children's Mercy, Jodi serves on the Hunger-Free Hospital Council and the Medical Advisory Board of the Food Equality Initiative. Today, she will enlighten us about the problem of food insecurity and food allergies in the pediatric population. Welcome, Jodi Shroba.
Jodi Shroba: Thank you. I'm so excited to be here today. And food allergy is one of my main focuses at work. And, obviously, the pandemic has brought food insecurity to light. So this is a good way to bring the two things together and talk about them as they do go hand in hand.
Dr Andrew Wilner (Host): When I was in medical school, I don't remember the term food insecurity. It seems to be sort of a new phrase. Could you define that for us?
Jodi Shroba: Sure. I feel like when I was in my grad school program, we didn't talk much about food insecurity either. So, I do feel like it's maybe one of those more buzzwords that you hear a lot more of today, same thing as shared decision-making is another one of those kind of buzzwords. But the definition of food insecurity is really the inability to provide enough safe nutritious food to meet your dietary requirements for people. And then, there's also the term very low food insecurity, which means that not only are you food insecure, but you're actually are adjusting your eating patterns because you do not have enough food to even provide for an adequate nutritional level.
Dr Andrew Wilner (Host): You know, this is the United States of America. Is this a problem?
Jodi Shroba: Sadly to say, yes. You would think we're the big, bad mighty United States and, sure, we have enough food for everybody to go around, but, sadly, that is not true. Some frightening statistics. In 2020, about 10% of US households were considered food insecure. So if you want to put that into numbers, that's 13.8 million people declared food insecurity in 2020. Those that were very low food insecure in 2020 we're about 3.9%, so about 5 million. While we do not have official numbers for 2021 yet, the projected model with the COVID pandemic is going to bump those numbers up to about 13% are food insecure. So again, 42 million people in this country report not having enough food to eat. And what really makes that sad is to think that 6.8% of these households have children that are reporting food insecurity.
Dr Andrew Wilner (Host): Sure. And, you know, it's important obviously for children to have proper nutrition for -- Well, I'm a neurologist -- for brain growth, for one thing, as well as a proper development in every way. And then on top of that, there's this problem of food allergies. The famous one, I guess, is peanuts. I remember I was on an airplane actually and a young child got ahold of the free peanuts. And luckily, the mother had the EpiPen, but it was quite a drama. How common is that?
Jodi Shroba: Well, the problem on the planes is actually is not common anymore since they have removed peanuts from airplanes. But in the United States, 32 million Americans have a food allergy. And of that, about 8% of children have a food allergy. So, again, throwing out percentages is sometimes hard for people to wrap their head around.
So if you want to think of a classroom of, say, 25 kids, two kids in every classroom are going to have a food allergy. And we do know that there are the top nine big food allergies. We used to say the top eight and sesame's getting added to that list. So the most common food allergies are peanuts, tree nuts, milk, egg, soy, wheat, finfish, shellfish and sesame.
Dr Andrew Wilner (Host): You know, the schools try and provide nutritious meals for children, but I think if they eliminated all of those, there's not much left. No milk, no soy, no nuts. So, do the schools take that into account, as they're trying to feed children healthy meals?
Jodi Shroba: They do. A lot of schools have gone peanut and tree nut-free. But like you mentioned, to have nutritious meals, you can't avoid, egg, milk, soy, wheat. You know, those are the foundations of most foods we eat. So those foods are still available. And part of my job is, not only do I clinically diagnose food allergies, but I have to teach families and children how to live in a world where their food allergy is around them.
If you think about food allergies, for example, I mean, we eat three meals a day, two snacks, maybe three snacks a day. Their main illness is always around them with food. And so we have to teach them how to safely navigate that world. And that's part of my job and that's probably the part of my job I love the most, is the education of how you can live with food allergies. And in part of where the food insecurity and food allergy comes together is because the only management currently for food allergy, because there is no cure, the only management is avoidance. And so for these kids to stay healthy, they need to not eat their allergen.
So then you talk about now you're relying on food assistance, whether it be through the schools or the Summer Meal Programs or WIC or SNAP, which is a supplemental nutrition program, formerly known as Food Stamps, or even food pantries, food banks, they can't accommodate maybe all of these necessities that children with food allergies have. And so they have to just get what they can get and then hand it out to families. And they talked about during the pandemic, you'd see those lines of cars lined up at the food banks and they would just put a box of food in the back of their car. And they didn't ask you, "Oh, do you have any dietary restrictions?" no, you got what you got. And that may be fine for a lot of people, but those with food allergies, they were still maybe not getting the foods that adequately met their nutritional needs. And so that's where that food allergy and food insecurity goes so hand in hand, because the treatment of food allergies is the avoidance of food. So then how do we get them safe food? And then if you don't have the money to afford them, I don't know if you've ever been to the grocery store and looked at the price difference between, say, a loaf of bread and a loaf of bread that does not have wheat in it, and the cost is enormous. If you look at the cost of a jug of milk, which we all know is very expensive. I was just at the store yesterday. I paid $5 for the jug of milk. For those that need to get, say, one of the nut milks or a soy milk, they're going to pay triple, quadruple that amount for a quarter of the amount. And so that's where the real problem comes in, is that the family still may be able to afford food for their children that don't have food allergies, they may not have the money to pay for these specialty foods because they are so expensive.
Dr Andrew Wilner (Host): Does food allergy include gluten intolerance? Does that fall into that category? I know that's very common.
Jodi Shroba: Yeah. So, we could do a whole podcast just on that. You might have to invite me back. So when you talk about a gluten intolerance, that is a problem of the GI system. So the GI system is unable to break down essentially the gluten. And gluten is used in a lot of foods. Primarily, it's used in a lot of our foods in America, at least as a filler and a preservative. And so, there really is not an allergic response to gluten. People that have trouble with wheat, that are allergic to wheat, that's an IgE, so meaning your immune system gets involved; where gluten intolerance is just that your body can't break it down, so it only involves the GI tract; where a food allergy is going to involve your entire immune system.
So there is a very big difference between the two. However, those with a wheat allergy, they will use the gluten-free products because of the fact that wheat and gluten go essentially hand in hand.
Dr Andrew Wilner (Host): Thank you for clarifying that. Now, tell us about your work with the American Academy of Allergy, Asthma and Immunology. I understand you did a survey.
Jodi Shroba: We did. So, probably through most medical specialties, there's always subcommittees of the varying diseases that your specialty treats. And so, we call it Quad AI. That's an easier way to say than American Academy of Allergy Asthma and Immunology. So through the Quad AI, we do have a subcommittee called the Adverse Reactions to Food Committee. And most of the members on there are people that do specialty work, subspecialize in food allergy, management, research. And so, through that subgroup, they kind of break that off and then you kind of have sub subcategories.
And so through the pandemic, we realized that there really wasn't kind of a subcategory to talk about food insecurity and what was being done for it. And I think before the pandemic, maybe all of us had our rose-colored glasses on, that maybe those social determinants of health really aren't a big deal in the specialty world. We knew they existed in primary care and we knew that primary care physicians took care of them. But in the specialty world, we kind of skated over them.
And so with the pandemic and seeing on the news about how people were just unable to get food, it sparked us to say, "Are we looking at food insecurity?" And again, going back to that, our patients, their treatment is avoidance of food. And so if they're insecure, what's going to happen? So we created this work group report and I had allergists on it. I had some psychologists on it. Nurses are on it. We even had some dieticians and then we had a community advocate from a food equality initiative, which is also an organization that helps those that are food insecure that have food allergies and celiac disease. And so we kind of came together as a group and we just said, "Let's talk about it. Let's find out what the allergy community is doing."
Now at the time that we sent the survey, I think there was a lot of maybe some survey fatigue or just people that were just-- you know, COVID was a big deal and people were dealing with a lot of things on top of it, so filling out a survey may have not been their first priority. But of the results that we got back, it was interesting to note that only about 25% of those that responded to the survey are actually screening for food insecurity. And about 70% said they weren't even talking about it with their family. Even if they weren't screening it, they weren't even having a discussion about it.
So we went ahead and created a work group report that we did explain the survey and kind of those results that we had. But then, from the survey, we learned that people didn't know how to screen for it. They didn't have enough information about what resources should you have if you have a family that's food insecure and just really didn't know how to even talk about food insecurity. So we almost kind of turned it into a how-to manual, where we provided varying food insecurity screenings that are available, mainly through our more primary care-based organizations, and then talking about some of those national and federal programs that can help and then maybe how you can start working with some of your local food banks and some of our allergy non-for-profit organizations to really kind of help our families. And just try to make practitioners feel more comfortable, bringing up a situation that is uncomfortable. People are sometimes afraid to admit that they need help. And so we really wanted to make a food insecurity screening feel normal and to feel like just the normal part of an exam, just like a normal part of an exam in every clinic is vital signs. So why not make screening for food insecurity like a vital sign? And that's why we use the hunger vital sign, which is a two-question survey just finding out what their needs are with food.
Dr Andrew Wilner (Host): Right. It's kind of like depression. You know, it's awkward to ask people, "Oh, are you suicidal?" You know, so there's I think a two-question depressions tool that's widely used now. And if you get a positive answer on one of the two, you better ask some more questions and try and help that person. But yeah, these are sensitive topics. Well, are there any important takeaways that you would like pediatricians to know?
Jodi Shroba: I want to always give kudos to our pediatric partners because social determinants of health has been something that's been screened in the primary care clinic, much longer than it's been screened in the specialty clinic. So, they were already doing this movement and now I think the movement is specialty care is going to get more involved with that. So that is my kudos to the primary care providers.
I think it's that we need to recognize that in a lot of diseases, and you being a neurologist, you know, think about your kids with epilepsy and they have special diets that they're on and, here in food allergy, we have kids that avoid food. So they're on special diets. GI providers have special diets based on their diagnosis. We could go down the list, diabetics.
I think that we need to really, as a medical community, start thinking about making food almost like a medicine and that we should be having prescription plans that will allow us as providers to write prescriptions for food and write prescriptions for foods that are necessary based on the diagnosis our patients have.
And so it really should be food is medicine, because food is so imperative to a lot of the diagnoses that we as specialty care take care of. And so I think that us working with our primary care partners, we could really build a big movement and start making some real policy change and some change on our insurance plans that allows us to write for food, because when you get down to the root of all medicine, diet is what keeps everybody healthy. And we need to get back together and work together to make food as acceptable as prescribing a pill.
And I hope that's what primary care providers will get out of today, is that food is so important and we need to all get on board making discussions about food insecurity not an uncomfortable conversation, and then also to come together to try to make food more accessible to all of our patients.
Dr Andrew Wilner (Host): Well, thanks for that. I think you might be onto something there. Jodi, thanks for enlightening us about food insecurity and food allergies in children.
Jodi Shroba: Well, thank you. And again, thank you for having me. And I look forward to seeing all of the medical community come together one day and we don't have to talk about food insecurity.
Dr Andrew Wilner (Host): This has been Pediatrics In Practice with Children's Mercy Kansas City. Please remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. To learn more about nutrition services at Children's Mercy, please visit childrensmercy.org. I'm your host, Dr. Andrew Wilner. Thanks for listening.