To improve health outcomes, ask patients about income, food access, housing

October 28, 2023

3 min read

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Key takeaways:

  • Addressing social determinants of health can improve health-related outcomes.
  • Use screening tools to assess food insecurity, housing and social support needs.

BOSTON — Patients struggling to meet cardiometabolic treatment targets may benefit from an assessment of social determinants of health, which could reveal food, housing or financial insecurity issues that play a large role in their health.

Approximately one in four U.S. adults with self-reported diabetes are achieving the “key goals” of an HbA1c level below 8%, BP below 140/90 mm Hg, non-HDL cholesterol below 130 mg/dL and not smoking, A. Enrique Caballero, MD, endocrinologist, clinical investigator and director of Latino Diabetes Health in the division of endocrinology, diabetes and hypertension at Brigham and Women’s Hospital; faculty director of the International Innovation Programs in the Office for External Education at Harvard Medical School; and immediate past chair for the Health Care Disparities Committee at the American Diabetes Association, said during a keynote address at the Cardiometabolic Health Congress.

A. Enrique Caballero, MD, quote

“The reality is that the impact we are having on our patients is not that great,” Caballero said. “The vast majority of our patients are not seeing the benefits discussed at this congress. The question is: Why are these benefits not positively affecting more individuals?”

For many patients in underresourced areas, social determinants of health, such as food access and food availability, neighborhood quality, income, occupation, access to health care and social support, all play a role in health outcomes, Caballero said. The disparities in care translate to excess health care costs. Approximately 70% of all expenses for diabetes care are related to the care of only 15% of the patients in the Medicare system; these patients are usually those with diabetes-related chronic complications and a large portion of them belong to racial and ethnic minorities, Caballero said.

“What may surprise people is that it is actually feasible to incorporate the evaluation of social determinants of health in routine clinical practice,” Caballero told Healio. “We just need to have a solid and concrete plan on how to work with members of our health care teams and make it part of our routine evaluations. Of course, having some tangible options to offer patients to solve some of their challenges is crucial as well. This requires identifying resources in the community. Health care professionals may be surprised how many community-based programs are available in their own community.”

Assessing patient needs, improving health

A patient deemed “nonadherent” to their medications or a prescribed lifestyle intervention often has relevant social factors that may explain why, Caballero said:

  • Assess a patient’s socioeconomic status by discussing their education and occupation. Data show cost-related or cost-reducing nonadherence is associated with income, insurance status and type of insurance, Caballero said, noting that even with insurance, high copays can make it difficult or impossible for a patient to afford their medicines. “I don’t think you would feel comfortable asking a patient, ‘Tell me how much money you make?’” Caballero said. “That is not the way to go. But ask about what they do, whether they have challenges with their medications. It may be uncomfortable sometimes, but it is important to ask whether what we are recommending even makes sense.”
  • Ask a patient about their neighborhood and physical environment, including housing and any toxic environmental exposures. As an example, issues such as neighborhood safety can impact whether a patient is able to exercise outdoors where they live, Caballero said.
  • Food insecurity can be assessed with a validated two-item screening tool, Caballero said. The first question should ask whether the patient worries whether their food would run out before they have money to buy more; the second question should ask if, within the past 12 months, the patient ran out of food and did not have money to get more, Caballero said. “This is a major issue; 14% of all people in the United States have food insecurity,” Caballero said. “Imagine how absurd [it would be] if I say to such a patient: ‘You should have a salad for lunch.’”
  • How do patients get support? Clinicians should ask patients who their support people are and if they have family or friends who can help with their self-care or with transportation to appointments.

Make time for social factors

The challenge, Caballero said, is to have these conversations with patients when a health care visit is 15 minutes or shorter; however, clinicians must get creative about assessing social factors.

“It is not good practice to say: ‘Do this and I’ll see you in 3 months,’” Caballero said. “Assessing all of these aspects is absolutely crucial. Perhaps a team can help gather this information. We need to become better at interacting with patients and eliciting these conversations in a meaningful way, and that calls for cultural humility, to interact with patients more effectively.”




Caballero AR. Screening for social determinants of cardiometabolic health & practice implications. Presented at: Cardiometabolic Health Congress; Oct. 18-21, 2023; Boston.

Caballero reports no relevant financial disclosures.


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