Food Insecurity: An Update on Implications for the Dental Team

Poverty and food insecurity in the UK

Overlapping vulnerabilities: food insecurity and health

It is widely accepted that upstream social determinants influence general and oral health at the level of the individual. Social determinants are social, environmental and cultural factors associated with societal level power differentials that lead to inequitable and unjust differences in health outcomes.²²

For example, people living in areas of deprivation may experience unstable employment or unemployment, poor quality housing, stigma and social exclusion, poverty, lower educational attainment and poor access to healthy food choices, which culminate in a disproportionate burden of chronic ill health.²³

Life expectancy is significantly reduced in areas of deprivation. For example, in 2020–2022, male life expectancy was highest in Hart (83.7 years) and lowest in Blackpool (73.4 years), a gap of more than a decade. Female life expectancy was highest in Kensington and Chelsea (86.3 years) and lowest in Blaenau Gwent (78.9 years), a gap of more than 7 years.²⁴

In the UK, diet is one of the leading causes of avoidable harm to health, and presents significant public health problems.²⁵ The relationship between limited access to healthy food, living in areas of deprivation and poorer health outcomes is well evidenced.² For example, food deserts and swamps are often located in areas of deprivation.²⁶ Food deserts are areas with low access to healthy foodstuffs. Food swamps have ready access and availability of low nutrient-dense food (i.e. fast-food outlets or small shops) and overly advertise processed foods. An additional challenge interlinking poverty and nutrition is experienced by families living in accommodation with little or no access to cooking facilities who struggle to prepare healthy foods.²⁷

Metabolic syndrome (a clustering of abdominal obesity, insulin resistance, dyslipidaemia and elevated blood pressure) is increased in people experiencing food insecurity.^28,29 Metabolic syndrome is associated with a two-fold increased risk of cardiovascular events or death and a five-fold increased risk of incident type 2 diabetes mellitus.^28,30 Furthermore, obesity is associated with many serious physiological, psychological and social consequences for children and adults, including high blood pressure,^31,32 heart disease,³³ diabetes,^30,32 pregnancy-related complications,³⁴ decreased life expectancy,³⁵ asthma,^36,37 depression^38,39 and stigmatization.^40,41 Diets containing high amounts of refined carbohydrates and sugars (i.e. foods with a high glycaemic index and load) can have a detrimental effect on psychological wellbeing.⁴² Inadequate dietary intake can affect a developing fetus, increasing the risk of birth defects, anaemia, low birth weight, preterm birth and developmental delay.^43–46

Food insecurity is linked to poorer management of health conditions including depression,^47,48 diabetes,^49–51 hypertension^48,51 and HIV.^48,52 For example, food-insecure adults are two to three times more likely to have diabetes than adults who are food-secure, even after controlling for important risk factors such as income, employment status, physical measures and lifestyle factors.^53,54 Food insecurity makes it especially difficult to avoid energy dense, nutritionally poor food to optimize glycaemic control, thus complicating optimum medical and insulin regimens.⁵⁵

Oral health and food insecurity

There are well-evidenced strong and consistent links between oral health and socio-economic status.³ The impacts of poor oral health disproportionately affect the most vulnerable and socially disadvantaged groups within our society.⁵⁶

Poor oral health can negatively affect quality of life leading to pain, infection, problems with eating, socializing and wellbeing. Dental disease can lead to time off work or school, with tooth decay continuing to be the most common reason for hospital admissions in children between the ages of 5 and 9 years.⁵⁷

Adults in routine and manual occupations experience higher levels of dental caries, unrestorable (severe) dental caries, periodontal diseases and tooth loss than their counterparts in managerial occupations.⁵⁸ More than one-third of children living in the most deprived areas of the UK experience dental decay; more than double that in the least deprived areas.⁵⁹ These examples illustrate how lower socio-economic status and deprivation are directly related to poorer oral health outcomes. However, emerging evidence suggests that beyond these mediating factors, food insecurity has a direct relationship with dental disease.^60–62

Studies have found that dental caries is 1.5 times more likely to be associated with high food-insecurity scores after adjusting for socio-economic status and gender.⁶³ Further, food insecurity is associated with a higher dental pain score,⁶⁴ dental pain at night,⁶⁵ increased experience with restorations and extractions,⁶⁶ increased frequency of prosthetic use⁶⁵ and untreated dental caries.^67–69 Decayed teeth may further interfere with eating leading to a restricted variety of foods, leading to a lower intake of protein, fibre and other nutrients (vitamins A, B and C, and folic acid), minerals (calcium, zinc and iron) and increased consumption of fats and carbohydrates.⁷⁰ People in a situation of food insecurity may opt for cheaper and cariogenic foods, often high in fat and sugar, which may result in an oral environment susceptible to the development of a biofilm that can lead to caries and gingivitis, along with consequent partial tooth loss and edentulism.^71–73

Additonally, compromised oral health can affect nutritional intake thereby impacting on non-communicable diseases (e.g. diabetes mellitus or obesity).⁷⁴ Nutritional imbalances can impact on the development of oral structures such as dysvitaminosis or modelling of gut microbiome and inflammation pathways.⁷⁵ Furthermore, oral diseases may have an impact on systemic health because the microbiome associated with oral diseases is commonly associated with the pathogenesis of multiple diseases, such as cardiometabolic, neurodegenerative, rheumatic and neoplastic conditions.⁷⁶

As food insecurity commonly results from deprivation and poverty, purchasing dental hygiene products or attending regular preventive appointments may be a lower priority when compared with putting food on the table. A recent report issued by the charity, Beauty Banks,⁷⁷ in association with the British Dental Association, found that 83% of secondary school teachers reported that they had given their students a toothbrush and toothpaste, and 81% stated that there are children who do not have regular access to these products.⁷⁷

Role of the dental team in supporting people experiencing food insecurity

Given the understanding of the impact of the social determinants of health, it is crucial for the dental profession to approach patients with a compassionate understanding that lifestyle changes may be difficult, or seemingly impossible, within certain contexts. The ability to make healthy dietary choices within the context of poverty is one such area; food insecurity can disadvantage individuals and create barriers to their ability to create healthy lifestyle changes. Resources such as the Eatwell guide and Change4Life have clear guidance about eating a healthy diet.^78,79 Dental professionals may need to explore how such national recommendations can fit within the limitations of food insecurity to avoid making patients feel disconnected by a one-size-fits-all approach. They can also have an active role in screening, signposting and data collection about people experiencing food insecurity.

The relationship between food insecurity is further complicated by social expectations regarding food choices. Food isn't eaten solely to satisfy functional requirements and is often associated with a sense of joy. In homes where people are living in poverty, sugary food can be a cheap and easy highlight in the day. Additionally, a parent, having experienced food deprivation in their own childhood may have the ‘desire to give their children whatever foods they request, so that the children might never feel denied or deprived’.⁸⁰

Therefore, conversations should be compassionate, non-judgemental, and sensitive to individual needs, while recognizing that an optimal diet may not always be achievable. It is important to appreciate the impact of multiple vulnerabilities that increase the complexity of people's lives. However, we recognize that dental professionals may not feel adequately equipped to discuss the sensitive topic of food insecurity or to provide tailored advice.⁸¹ To support the general dental practitioner, we describe recommendations and suggestions for practice in the following section.

Recommendations

There are several validated food insecurity screening tools that quantify the scale of individual food insecurity, which are simple and easy to use, including a two-question screening tool with 97% sensitivity.⁸²

This could be added to health questionnaires to identify those that might benefit from a further discussion (Table 1).

Patients may have developed trust and rapport with their dental practitioner and may feel comfortable sharing their information. To obtain a detailed social history, clinicians may also consider undertaking training in basic and motivational interviewing, and challenge themselves to examine their own biases as unexplored prejudices, which may influence the ability to act on, or obtain, important information.⁸³

While general medical practitioners, local councils and Citizen's Advice can currently refer individuals to local food banks, this process could also be adopted for general dental practitioners.

Dental teams can also help by identifying resources within their communities and local schools, positioning their teams within the wider healthcare multidisciplinary teams, or linking to social prescribing to focus on individuals with social vulnerability. They can promote awareness of local initiatives to ensure patients have adequate access to support when needed. There are several organizations that can offer further information (Table 2).

In addition, public oral health programmes in low-income urban and rural areas, such as toothbrushing schemes or reduction in sugar in food and beverages, can contribute to a reduction of dental diseases and the burden of chronic disease.^84,85

At this time, not enough is known about how dental professionals engage with patients in conversations related to food insecurity, what oral health-related dietary advice is given in these scenarios, and how people experiencing food insecurity feel about discussing their diet in dental settings. We recommend that future research focuses on the practicalities of providing dental care for people experiencing food insecurity and how this can be done in the most appropriate, respectful and compassionate way.

While the availability of food banks and food spaces may help to increase access to food for many, it is important to remember that this alone does not solve underlying problems of poverty. The governing bodies of dentistry must continue to advocate for policies that reduce inequalities, as well as supporting change to improve dental access for the most vulnerable in society.

Conclusion

The oral health implications of food insecurity directly affect individual dental patients and the wider health system. Further, it is important for the dental team to understand the relationship between food insecurity and oral health, and to reflect upon what impact food insecurity may have for dental care and the provision of tailored dietary advice. It is imperative that we continue to raise awareness of food insecurity among the dental profession to ensure we fulfil our duty of care to our most vulnerable patients.