Portal de Periódicos da CAPES

Food insecurity: A key determinant of health

2020; Elsevier BV; Volume: 35; Issue: 1 Linguagem: Inglês

10.1016/j.apnu.2020.10.011

1532-8228

Melissa Hawkins, Anthony D. Panzera,

Child Nutrition and Water Access

Food insecurity, broadly defined as a lack of access to sufficient quantity of affordable and nutritious food (US Department of Agriculture, 2019US Department of Agriculture Definitions of food security.https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspxDate: 2019Google Scholar), is a social and economic condition with health consequences across the lifespan including poor dietary intake, physical health, and increased risk for chronic diseases and mental health conditions (Ferrer et al., 2019Ferrer R.L. Neira L.-M. De Leon Garcia G.L. Cuellar K. Rodriguez J. Primary care and food Bank collaboration to address food insecurity: A pilot randomized trial.Nutrition and Metabolic Insights. 2019; https://doi.org/10.1177/1178638819866434Crossref PubMed Google Scholar, Liu et al., 2014Liu Y. Njai R.S. Greenlund K.J. Chapman D.P. Croft J.B. Relationships between housing and food insecurity, frequent mental distress, and insufficient sleep among adults in 12 US states, 2009.Preventing Chronic Disease. 2014; 11: 130334Crossref Scopus (68) Google Scholar; World Health Organization and Calouste Gulbenkian Foundation, 2014World Health Organization and Calouste Gulbenkian Foundation Social determinants of mental health. World Health Organization, Geneva2014Google Scholar). Risk factors for many mental health conditions are significantly correlated with adverse social conditions (World Health Organization and Calouste Gulbenkian Foundation, 2014World Health Organization and Calouste Gulbenkian Foundation Social determinants of mental health. World Health Organization, Geneva2014Google Scholar). Mental illness is more prevalent among individuals who experience food insecurity; furthermore, mental health conditions and food insecurity co-occur disproportionately among more women than men (Martin et al., 2016Martin M.S. Maddocks E. Chen Y. Gilman S.E. Colman I. Food insecurity and mental illness: Disproportionate impacts in the context of perceived stress and social isolation.Public Health. 2016; 132: 86-89https://doi.org/10.1016/j.scitotenv.2019.135881Crossref PubMed Scopus (15) Google Scholar). Chronic conditions including obesity (Hales et al., 2020Hales C.M. Carroll M.D. Fryar C.D. Ogden C.L. Prevalence of obesity and severe obesity among adults: United States, 2017–2018.in: NCHS data brief, no 360. 2020. National Center for Health Statistics, Hyattsville, MD2020Google Scholar), diabetes (Divers et al., 2020Divers J. Mayer-Davis E.J. Lawrence J.M. Isom S. Dabelea D. Dolan L. Hamman R.F. Trends in incidence of type 1 and type 2 diabetes among youths—Selected counties and Indian reservations, United States, 2002–2015.Morbidity and Mortality Weekly Report. 2020; 69: 161Crossref PubMed Google Scholar), hypertension (Fryar et al., 2017Fryar C.D. Ostchega Y. Hales C.M. Zhang G. Kruszon-Moran D. Hypertension prevalence and control among adults: United States, 2015–2016.in: NCHS data brief, no 289. National Center for Health Statistics, Hyattsville, MD2017Google Scholar), heart disease, and several types of cancer (Weir et al., 2016Weir H.K. Anderson R.N. King S.M.C. Soman A. Thompson T.D. Hong Y. Leadbetter S. Peer reviewed: heart disease and cancer deaths—Trends and projections in the United States, 1969–2020.Preventing Chronic Disease. 2016; : 13Google Scholar) are associated with poor nutrition and all are growing among global populations, particularly in low-income communities (Singh et al., 2017Singh G.K. Daus G.P. Allender M. Ramey C.T. Martin E.K. Perry C. de los Reyes, A.A. & Vedamuthu, I. P. Social determinants of health in the United States: Addressing major health inequality trends for the nation, 1935–2016.International Journal of MCH and AIDS. 2017; 6: 139Crossref PubMed Google Scholar). In the US, almost fifty million individuals are food insecure, of which nearly 20% are children. Food insecure households spend 45% more annually on medical care than those in food secure homes (Berkowitz et al., 2018Berkowitz S.A. Basu S. Meigs J.B. Seligman H.K. Food insecurity and health care expenditures in the United States, 2011–2013.Health Services Research. 2018; 53: 1600-1620https://doi.org/10.1111/1475-6773.12730Crossref PubMed Scopus (87) Google Scholar), further demonstrating the acute interconnectivity of the social, economic, and medical experiences of low-income American communities. Food system inequities drive both hunger and chronic disease risks. Additionally, disadvantaged communities are most impacted by mental health conditions, which compounds the effects of socio-economic determinants throughout the lifespan (Allen et al., 2014Allen J. Balfour R. Bell R. Marmot M. Social determinants of mental health.International Review of Psychiatry. 2014; 26: 392-407Crossref PubMed Scopus (320) Google Scholar). Risk factors for diet-related conditions are more prevalent in low-income areas (Drewonwski and Spector, 2004Drewonwski A. Spector S. Poverty and obesity: The role of energy density and energy costs.The American Journal of Clinical Nutrition. 2004; 74: 6-16Crossref Scopus (1639) Google Scholar). Food purchasing decisions are influenced by travel time to shopping, availability of healthful foods, availability of personal funds, and food prices (King, 2017King C. The food environment and social determinants of food insufficiency and diet quality in rural households.in: The intersection of food and public health. Routledge, 2017: 87-106Crossref Google Scholar). Individuals living in food deserts and food swamps face barriers to accessing healthy and affordable food. A food desert is defined as a low-income community with limited access to affordable and nutritious food and are often characterized by measuring the distance between people's homes and supermarkets (Ver Ploeg et al., 2009Ver Ploeg M. Breneman V. Farrigan T. Hamrick K. Hopkins D. Kaufman P. Williams R. Access to affordable and nutritious food: Measuring and understanding food deserts and their consequences. United States Department of Agriculture Economic Research Service, Washington, DC, USA2009Google Scholar). Individuals who live in food deserts are also at greater risk for obesity (Cooksey-Stowers et al., 2017Cooksey-Stowers K. Schwartz M.B. Brownell K.D. Food swamps predict obesity rates better than food deserts in the United States.International Journal of Environmental Research and Public Health. 2017; 14: 1366https://doi.org/10.3390/ijerph14111366Crossref Scopus (124) Google Scholar). Communities where fewer supermarkets are available also tend to have a higher number of corner stores, which typically stock energy-dense, shelf-stable foods that are nutrient-poor foods (Bodor et al., 2010Bodor J. Ulmer V. Dunaway L. et al.The rationale behind small food store interventions in low-income urban neighborhoods: Insight from New Orleans1-3.The Journal of Nutrition. 2010; 140: 1185-1188Crossref PubMed Scopus (64) Google Scholar). On the other hand, food swamps are defined as areas with a high-density of stores selling high-calorie fast food, relative to healthier food options (Hager et al., 2017Hager E.R. Cockerham A. O'Reilly N. Harrington D. Harding J. Hurley K.M. Black M.M. Food swamps and food deserts in Baltimore City, MD USA: Associations with dietary behaviors among urban adolescent girls.Public Health Nutrition. 2017; 20: 2598-2607Crossref PubMed Scopus (55) Google Scholar). A recent study by Cooksey-Stowers et al., 2017Cooksey-Stowers K. Schwartz M.B. Brownell K.D. Food swamps predict obesity rates better than food deserts in the United States.International Journal of Environmental Research and Public Health. 2017; 14: 1366https://doi.org/10.3390/ijerph14111366Crossref Scopus (124) Google Scholar demonstrated that food swamps are a stronger predictor of obesity rates among adults than food deserts, suggesting it is necessary for food environment descriptions to include the availability of both healthy and unhealthy food quality to accurately depict the nutrition environment low-income communities encounter on a daily basis. The number of Americans assessed to be food insecure has been variable, with reports of between 35 to more than 50 million, and impacted by race, geographic location, employment status, poverty level, level of education attained and societal drivers such as the recession of 2008–2010 and the current COVID pandemic (Coleman-Jensen et al., 2019Coleman-Jensen A. Rabbitt M.P. Gregory C.A. Singh A. Household food insecurity in the United States in 2018. ERR-270. U.S. Department of Agriculture, Economic Research Service, 2019Google Scholar; Feeding America, 2020Feeding America The impact of the coronavirus on local food insecurity.feedingamerica.orgDate: May 19, 2020Google Scholar; Gunderson and Ziliak, 2015Gunderson C. Ziliak J.P. Food insecurity and health outcomes.Health Affairs. 2015; 34: 1830-1839https://doi.org/10.1377/hlthaff.2015.0645Crossref Scopus (478) Google Scholar). In school-age children, hunger impacts their ability to concentrate which results in lower academic performance, complaints of headaches and stomachaches and can contribute to disruptive behaviors (Bergman et al., 2019Bergman R.S. Sadler R.C. Wolfson J.A. Jones A.D. Kruger D. Moderation of the association between individual food security and poor mental health by local food environment among adult residents of Flint, Michigan.Health Equity. 2019; 3: 264-274https://doi.org/10.1089/heq2018.0103Crossref PubMed Google Scholar; Bernard et al., 2018Bernard R. Hammarlund R. Bouquet M. Ojeuole T. Kirby D. Grizzaffi J. McMahon P. Parent and child reports of food insecurity and mental health: Divergent perspectives.Ochsner Journal. 2018; 18: 318-325Crossref PubMed Scopus (4) Google Scholar). In adults, food insecurity has been associated with shame, despair, anxiety and depression, hopelessness, chronic stress, inability to afford and use mental health services and a variety of worrisome behaviors associated with obtaining food (Afulani et al., 2018Afulani P.A. Coleman-Jensen A. Herman D. Food insecurity, mental health and use of mental health services among nonelderly adults in the United States.Journal of Hunger and Environmental Nutrition. 2018; 15: 29-50https://doi.org/10.1080/19320248.2018.1537868Crossref Scopus (9) Google Scholar; Bergman et al., 2019Bergman R.S. Sadler R.C. Wolfson J.A. Jones A.D. Kruger D. Moderation of the association between individual food security and poor mental health by local food environment among adult residents of Flint, Michigan.Health Equity. 2019; 3: 264-274https://doi.org/10.1089/heq2018.0103Crossref PubMed Google Scholar; Jones, 2017Jones A.D. Food insecurity and mental health status: A global analysis in 149 countries.American Journal of Preventive Medicine. 2017; https://doi.org/10.1016/jamepre.2017.04.008Crossref Google Scholar). The complex interactions between food insecurity, poverty, and chronic disease prevention and management (including the treatment and management of mental illnesses and experiences) requires an understanding of the non-medical drivers of health. Equity in food security is integrally connected to health, employment, housing, and education; these concepts are often characterized as "the social determinants of health (SDH)." A two-way path exists between mental illness and social determinants; poor mental health can influence a person's experience of social determinants while social determinants can moderate a person's experience of mental health (World Health Organization and Calouste Gulbenkian Foundation, 2014World Health Organization and Calouste Gulbenkian Foundation Social determinants of mental health. World Health Organization, Geneva2014Google Scholar). Thus, socially-mediated approaches may be effective at improving nutritional and clinical (and, perhaps, sub-clinical) outcomes. Access to affordable, nutritious food can improve health and decrease risk of chronic diseases; however, food security includes both the access to food and the nutritional quality of food as the foundation to overall health and wellness. Access to healthy food may not be enough to prevent chronic diseases, as individuals require additional support to access food, adopt dietary patterns, and change behaviors (Kihlstrom et al., 2019Kihlstrom L. Long A. Himmelgreen D. Barriers and facilitators to the consumption of fresh produce among food pantry clients.J Hunger Env Nutr. 2019; 14: 168-182Crossref Scopus (8) Google Scholar). Community health programming and larger public health efforts attempt to tackle outcomes by addressing these interconnected SDH. Food insecurity and low income status, along with their concomitant health-compromising coping strategies, can exacerbate existing mental health and other chronic conditions. For example, engaging in cost-related medication underuse or non-adherence (e.g., skipping medications, taking less medication than prescribed, delaying prescription refills, using lower cost medications) (Herman et al., 2015Herman D. Afulani P. Coleman-Jensen A. Harrison G.G. Food insecurity and cost-related medication underuse among nonelderly adults in a nationally representative sample.American Journal of Public Health. 2015; 105: 48-59Crossref Scopus (36) Google Scholar; Knight et al., 2016Knight C.K. Probst J.C. Liese A.D. Sercy E. Jones S.J. Household food insecurity and medication "scrimping" among US adults with diabetes.Preventive Medicine. 2016; 83: 41-45Crossref PubMed Scopus (26) Google Scholar) and postponing health care (Kushel et al., 2006Kushel M.B. Gupta R. Gee L. Haas J.S. Housing instability and food insecurity as barriers to health care among low- income Americans.Journal of General Internal Medicine. 2006; 21: 71-77Crossref PubMed Scopus (381) Google Scholar) exacerbate those same health conditions. The complexity of these issues requires comprehensive and interconnected health approaches that account for emotional and psychological vulnerabilities. Although the evidence is consistent and compellingly supports the effectiveness of improved access to food programs and the improvement of a variety of health outcomes, gaps in confirmation of the effectiveness of combined, public health strategies with multi-sectoral partnerships exist (Thornton et al., 2016Thornton R.L. Glover C.M. Cené C.W. Glik D.C. Henderson J.A. Williams D.R. Evaluating strategies for reducing health disparities by addressing the social determinants of health.Health affairs (Project Hope). 2016; 35: 1416-1423https://doi.org/10.1377/hlthaff.2015.1357Crossref PubMed Scopus (125) Google Scholar). Comprehensive, socially-mediated interventions have the potential to transform perceived nutritional 'barriers' – such as lack of coordination across medical, community health, and social programming – into integral components of education- and self-efficacy-focused nutritional interventions, empowering patients to navigate the complexities of the food and health-mental health care continuum and assisting them in this dynamic process. One such intervention, care coordination, goes beyond service provision. Populations that are being treated with medications such as antidepressants or antipsychotics may, individually, have differential side effects related to their medication use. For example, known associations exist among use of antipsychotics and diabetes status (Holt, 2019Holt R.I. Association between antipsychotic medication use and diabetes.Current Diabetes Reports. 2019; 19: 96Crossref PubMed Scopus (17) Google Scholar). Personalized interventions targeting the uniquely complex factors experienced by individuals utilizing pharmacological treatments for mental illness, such as lifestyle interventions that target medication-related weight gain (Curtis et al., 2016Curtis J. Watkins A. Rosenbaum S. Teasdale S. Kalucy M. Samaras K. Ward P.B. Evaluating an individualized lifestyle and life skills intervention to prevent antipsychotic-induced weight gain in first-episode psychosis.Early Intervention in Psychiatry. 2016; 10: 267-276Crossref PubMed Scopus (121) Google Scholar; Teasdale et al., 2017Teasdale S.B. Ward P.B. Rosenbaum S. Samaras K. Stubbs B. Solving a weighty problem: Systematic review and meta-analysis of nutrition interventions in severe mental illness.The British Journal of Psychiatry. 2017; 210: 110-118Crossref PubMed Scopus (87) Google Scholar), could address the nexus of mental health, nutrition, and chronic health outcomes directly. Health care and food access programs can serve as partners in efforts toward health promotion, improving food security, and the prevention and management of chronic diseases, including mental illness. Many food banks in low-income communities have developed supply chains for fresh produce or even grow their own fruits and vegetables (Wetherill et al., 2018Wetherill M.S. White K.C. Rivera C. Seligman H.K. Challenges and opportunities to increasing fruit and vegetable distribution through the US charitable feeding network: Increasing food systems recovery of edible fresh produce to build healthy food access.J Hunger Env Nutr. 2018; 26: 1-20Google Scholar). Other health advocates promote chronic disease management by offering education such as chronic disease self-management in hospital and clinic settings (Seligman and Schillinger, 2010Seligman H.K. Schillinger D. Hunger and socioeconomic disparities in chronic disease.The New England Journal of Medicine. 2010; 363: 6-9Crossref PubMed Scopus (238) Google Scholar). A recent intervention trial, which bundled healthy food allotments with diabetes self-management education delivered at 27 food pantries, improved food security and intake of fruits and vegetables (Seligman and Schillinger, 2010Seligman H.K. Schillinger D. Hunger and socioeconomic disparities in chronic disease.The New England Journal of Medicine. 2010; 363: 6-9Crossref PubMed Scopus (238) Google Scholar). Additional community intervention efforts to reduce nutritional health risks include referrals to resources such as federal nutrition programs or food pantries, assistance with nutrition benefits and enrollment, food from on-site gardens, meal delivery programs, food-as-medicine programs, and produce vouchers that can be redeemed at farmers' markets (Lundeen et al., 2017Lundeen A. Siegel K.R. Calhoun H. Clinical-community partnerships to identify patients with food insecurity and address food needs.Prev Chronic Dis. 2017; 14E113Crossref PubMed Scopus (24) Google Scholar). These community-based partnerships have shown promising preliminary results to increase food security among low-income populations. Nurses can play a vital role in promoting health equity and addressing SDH as it relates to food insecurity. A team-based approach is necessary to address SDH in the health care setting. The relationship between the food environment, neighborhood factors, and health outcomes must be considered when counseling patients on their risk of obesity and other chronic conditions. Nurses have the opportunity to promote health and the prevention of chronic diseases by incorporating food security/insecurity questions in routine medical and mental health assessments and through nutrition education. Although nurses of all sub-fields may have limited time to engage in nutrition education, nurses can advocate for or directly refer to nutrition programs to cover these necessary and relevant services. Nurses can help to identify food insecure individuals, facilitate access to community resources, and advocate for food and nutrition polices that address SDH. From a patient-care perspective, need exists for seasoned healthcare providers, like nurses, that typically provide health education to patients to provide nutrition education tailored for the unique lived experiences of, say, mentally ill or cognitively impaired populations. Strategies for providing nutrition education among those with serious mental illness are few but growing (Gidugu and Jacobs, 2019Gidugu V. Jacobs M.L. Empowering individuals with mental illness to develop healthy eating habits through mindful eating: Results of a program evaluation.Psychology, Health & Medicine. 2019; 24: 177-186Crossref PubMed Scopus (3) Google Scholar). Despite the growing recognition of the importance of SDH, there is a lack of evidence for effective scalable strategies to address social determinants, particularly in low-income communities and among vulnerable individuals who are mentally ill (Alegría et al., 2018Alegría M. NeMoyer A. Falgàs Bagué I. Wang Y. Alvarez K. Social determinants of mental health: Where we are and where we need to go.Current Psychiatry Reports. 2018; 20: 95https://doi.org/10.1007/s11920-018-0969-9Crossref PubMed Scopus (41) Google Scholar; Gottlieb et al., 2017Gottlieb L.M. Wing H. Adler N.E. A systematic review of interventions on patients' social and economic needs.American Journal of Preventive Medicine. 2017; 53: 719-729Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar). Given limited food system access, limited time of clinicians, and the challenges inherent in the lives of low-income individuals, investment in interventions are necessary if nurses are going to be a significant partner in efforts to reduce the steady rise in chronic diseases. The necessity to reduce health disparities in chronic diseases has led to an increased interest in nurse-led interventions in the US. Nurse-led interventions have demonstrated promise in improving health behaviors. A review of 39 effective intervention models (Martsolf et al., 2016Martsolf G.R. Gordon T. May L.W. Mason D. Sullivan C. Villarruel A. Innovative nursing care models and culture of health: Early evidence.Nursing Outlook. 2016; 64: 367-376https://doi.org/10.1016/j.outlook.2016.02.009Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar) created by nurses found the majority focused on the following SDH imperatives: strengthening integration of health services and systems; fostering cross-sector collaboration to improve well-being; creating healthier, more equitable communities; and supporting health and well-being as a shared value among the health-care team. Indeed, across all effective interventions is the role of partnerships and weaving together program services all aimed at enhancing the health of vulnerable populations. Moreover, in other evaluations of chronic disease management interventions targeting underserved populations, participating communities were not actively involved in the identification of needs or in developing, implementing, and evaluating those interventions, which may have constrained effectiveness and potential sustainability. While partnerships across programs and institutions is important, it is just as important to include vulnerable populations in the development of the services provided to them. An extended role of nurses within health care teams to lead interventions that address SDH has the potential to advance health equity using upstream approaches that are culturally competent, affordable, patient-centered (Ortiz, 2020Ortiz M.R. Patient-centered medical (health) home: Nursing theory-guided policy perspectives.Nursing Science Quarterly. 2020; 33: 91-96Crossref PubMed Scopus (1) Google Scholar) and explicitly include the voices of the vulnerable. Nurses have been at the forefront of the COVID-19 pandemic response (Jackson et al., 2020Jackson D. Bradbury-Jones C. Baptiste D. Gelling L. Morin K. Neville S. Smith G.D. Life in the pandemic: Some reflections on nursing in the context of COVID-19.Journal of Clinical Nursing. 2020; 29: 2041-2043Crossref PubMed Scopus (118) Google Scholar). Food insecurity in the time of the COVID-19 pandemic illustrates the complexities of food inequity. In the US, approximately 35 million households rely on the Supplemental Nutrition Assistance Program (SNAP) (Food and Nutrition Service, 2020aFood & Nutrition Service SNAP data tables: National level annual summary. U.S. Department of Agriculture. April 10.https://www.fns.usda.gov/pd/supplemental-nutrition-assisstance-program-snapDate: 2020Google Scholar) and 7 million women rely on the Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) (Thorn et al., 2018Thorn B. Kline N. Tadler C. Budge E. Wilcox-Cook E. Michaels J. Tran V. WIC participant and program characteristics 2016. U.S. Department of Agriculture, Food and Nutrition Service, Alexandria, VA2018Google Scholar); both Federally-funded programs help meet the needs of low-income children and families who are food insecure, at nutrition risk, and are currently practicing social isolation. Applications, certifications, and meal provisions for these programs have increased significantly since the COVID-19 pandemic began in the US in early 2020 (Food and Nutrition Service, 2020bFood & Nutrition Service FNS response to COVID-19. U.S. Department of Agriculture. April 20.https://www.fns.usda.gov/disaster/pandemic/covid-19Date: 2020Google Scholar; Food and Nutrition Service, 2020cFood & Nutrition Service Questions and answers related to COVID-19: WIC and the food distribution programs. U.S. Department of Agriculture. April 20.https://www.fns.usda.gov/disaster/pandemic/covid-19Date: 2020Google Scholar). Some state SNAP, WIC, and child nutrition programs have applied for waivers to give beneficiaries more flexibilities in accessing and purchasing a wider range of foods and non-covered necessities to meet the needs of vulnerable households (US Department of Agriculture, 2020aUS Department of Agriculture SNAP state-by-state COVID-19 waivers.https://www.fns.usda.gov/disaster/pandemic/covid-19/snap-waivers-flexibilitiesDate: 2020Google Scholar, US Department of Agriculture, 2020bUS Department of Agriculture WIC state-by-state COVID-19 waivers.https://www.fns.usda.gov/disaster/pandemic/covid-19/wic-waivers-flexibilitiesDate: 2020Google Scholar, US Department of Agriculture, 2020cUS Department of Agriculture Child nutrition program state-by-state COVID-19 waivers.https://www.fns.usda.gov/disaster/pandemic/covid-19/cn-waivers-flexibilitiesDate: 2020Google Scholar). Approximately 50 million children receive food and/or breakfast at school each day. States are responding to the increasing needs in different ways, but food access and distribution remains a central challenge to implementation of program services (Dunn et al., 2020Dunn C.G. Kenney E. Fleischhacker S.E. Bleich S.N. Feeding low-income children during the Covid-19 pandemic.New England Journal of Medicine. 2020; https://doi.org/10.1056/NEJMp2005638Crossref PubMed Scopus (103) Google Scholar). COVID-19 has exacerbated the long-standing and interconnected SDH in socioeconomically disadvantaged communities. Layered on top of food insecurity issues are a myriad preexisting diagnosed physical and mental health co-morbidities that burden minority and low-income Americans disproportionately. Low-income communities bear a disproportionate, pandemic-related burden due to increased food insecurity that persists beyond the cessation of initial social efforts to reduce the community spread of SARS-CoV-2. The World Health Organization has already reported on general increases of pandemic-related mental illnesses experienced by both the general population and the healthcare workforce (World Health Organization, 2020World Health Organization Substantial investment needed to avert mental health crisis.https://www.who.int/news-room/detail/14-05-2020-substantial-investment-needed-to-avert-mental-health-crisisDate: 2020Google Scholar), which underscores the interconnectedness of the COVID-19 pandemic, mental health, and the nutritional life of populations globally. Despite planned re-openings of society across the US in state-level "phased" processes, people with pre-existing mental illnesses will need to readjust their health management again, and those who have pandemic-related mental illness such as depression or post-traumatic stress will need access to mental health professionals. The pandemic invites a shift in thinking about equity, particularly with regard to ensuring that basic needs of food, housing, and education are met. Furthermore, SDH are the result of structural inequalities in institutional systems, not individual patient vulnerabilities (Adler et al., 2016Adler N.E. Cutler D.M. Jonathan J. Galea S. Glymour M. Koh H. et al.Addressing social determinants of health and health disparities: National Academy of Medicine.2016Google Scholar). This key distinction may be challenging for nurses and health care providers who deliver care on an individual basis. However, this necessary shift in framing is critical for changing attitudes and providing care to understand disadvantage due to long-standing structural inequalities. A shift in healthcare providers' perceptions of the community care networks within which they operate can spark creative integration and streamlining of mental health and nutrition services. A "food equity approach" is an emerging framework for using policy to reduce health disparities. Efforts to address SDH and promote health beyond health care is growing, which is evident in the shift of American national health priorities. We are in the midst of an evolution from traditional, individual behavior approaches to innovative, systems approach that focuses on community health and multi-sector partnerships that relieve the burden of addressing all of society's ills from one healthcare provider. As such, system-focused approaches are necessary for engaging communities in support of societal level reforms to reduce food insecurity and better reap the value of community programs like SNAP and WIC. The Equity-Oriented Obesity Prevention framework (Kumanyika, 2019Kumanyika S.K. A framework for increasing equity impact in obesity prevention.American Journal of Public Health. 2019;