Guest Host: Marc Fisher

A recent study shows that poor people with diabetes are significantly more likely to end up in the hospital for dangerously low blood sugar at the end of the month, when budgets are tight. As Congress debates cuts to food assistance programs like SNAP benefits, some doctors and advocates for the poor say the study is further evidence that cutting food and other assistance programs leads to expensive health care crises. We explore the issues.


  • Hilary Seligman Professor of Medicine, University of California San Francisco
  • Leighton Ku Professor, Dept. of Health Policy; Director, Center for Health Policy Research; School of Public Health and Health Services, George Washington University


  • 13:33:29

    MR. MARC FISHERWelcome back. I'm Marc Fisher of the Washington Post sitting in for Kojo. A recent study shows that poor people with diabetes are significantly more likely to end up in the hospital for dangerously low blood sugar at the end of the month when budgets are tight. Researchers have known for a long time that the end of the month is a tough time for the poor. But if running out of food money turns out to lead directly to expensive trips to the emergency room, this study could have important policy implications, especially now as congress debates cuts to food assistance programs and whether to extend unemployment insurance.

  • 13:34:04

    MR. MARC FISHERJoining us to discuss this are Hilary Seligman who is a professor of medicine at the University of California at San Francisco. Welcome to the program.

  • 13:34:14


  • 13:34:14

    FISHERAnd Leighton Ku is professor of health policy and he's the director of the Center for Health Policy Research at the School of Public Health and Health Services at George Washington University. Thanks for joining us on a snowy day.

  • 13:34:26

    DR. LEIGHTON KUGlad to be here.

  • 13:34:27

    FISHERWell, Hilary Seligman, let's start with you and tell us what -- about your work and how you came to study this issue, and why you looked particularly at diabetes.

  • 13:34:39

    SELIGMANMy interest is in hunger, or what we refer to more generally as food insecurity, going hungry or feeling as if you may not have enough money to feed yourself at your next meal, and what implications this has on people's health. Both -- implications for preventing chronic disease like obesity, diabetes, high blood pressure, heart failure and once you have these diseases, what effects does that have on your ability to manage these diseases.

  • 13:35:08

    SELIGMANAnd I have been working in this area for many years and noticed, like many people who work in this area, that demand for emergency food goes up at the end of the month. Lines at soup kitchens are longer, lines at food pantries are longer. And the real question that drove me to this article was, what implications does that have for people's health.

  • 13:35:29

    FISHERAnd so what exactly did you look at and what was the strategy or theory behind this experiment?

  • 13:35:38

    SELIGMANWe chose to look at people with diabetes. And the reason why is because when you have diabetes, your health care provider chooses the amount of medication to put you on based on an assumption that you're going to have about the same amount of food to eat every day, because your diabetes medicine is going to lower your blood sugar. And if you don't eat, your blood sugar will go down too much.

  • 13:36:00

    SELIGMANAnd so we speculated that if people were running out of money for food at the end of the month, that these episodes of too low blood sugar, what physicians call hypoglycemia, would be more likely to occur at the end of the month. So what we did is we looked at all hospital admissions in the State of California over an eight-year period and pulled out those admissions that were for a diagnosis of very low blood sugar. And then looked at whether there was a monthly pattern.

  • 13:36:29

    SELIGMANAnd what we found was that within the high income population, the admissions for low blood sugar were about constant throughout the entire month. But in the low income population, admissions for low blood sugar increased by 27 percent in the last week of the month compared to the first week of the month.

  • 13:36:47

    FISHERAnd so that tells you that people were running low on money and making different food choice or having no choices and running into trouble with their health.

  • 13:36:57

    SELIGMANThis is what we speculate, that the reason for this 27 percent increase in hospital admissions for low blood sugar is that people are running out of money for food. They continue to take their diabetes medicines. They've been urged to do this by our health care system to take their medicines every day, but without money for food their blood sugar falls dangerously low.

  • 13:37:18

    FISHERYou can join our conversation by calling 1-800-433-8850. Let us know if you've seen firsthand how tight budgets can lead to health issues. Have you seen how for those in poverty the end of the month can mean more trips to the emergency room? And what's your view of the logic behind cutting food assistance and unemployment benefits, 1-800-433-8850? Or email us at And Leighton Ku, what do you make of this study's conclusion? Is it persuasive at all that this end-of-the-month phenomenon would be tied to running out of money, and therefore eating the wrong foods or not eating healthfully?

  • 13:38:02

    KUI think Dr. Seligman's conclusion is a reasonable one. She's cautious and rightly so. There are other possible reasons why people might have episodes of hypoglycemia. So, for example, even if it's related to diabetes, if people have problems related to nausea then they might eat less, regardless of what their food budget is, or if they have gastrointestinal problems that can lead to similar things where they're not able to stay in their blood sugar levels. Nonetheless, those things occurring, as she's indicating, at the end of the month, month after month after month really do suggest that there's a pattern.

  • 13:38:41

    KUAnd so whether it is per say just food budgets are other sorts of stress. I mean, let's face it, low-income people are living on a day-to-day month-to-month budget. There could be all sorts of stresses that occur towards the end of the month that can lead to some of these problems. The explanation that has to do with food budgets is really quite sensible. We've known for a long time that food stamp benefits, these days called SNAP or Supplemental Nutrition Assistance Program, benefits often run out towards the end of the month. So the story seems, you know, very compelling.

  • 13:39:18

    FISHERAnd so do you -- given that there are these other potential stress factors and people have rent payments to make and that sort of thing, if their money is running low, could those other stressors lead to these sort of medical incidents that you're seeing toward the end of the month that could have nothing to do with food?

  • 13:39:37

    KUI think there could be some other factors. Again, you know, it may be better to actually ask Dr. Seligman, who's actually a medical doctor -- I'm not a medical doctor -- what are some of these other factors. Certainly it's possible that there are other explanations but the one that she points to is probably the one that seems the most plausible.

  • 13:39:58

    FISHERAnd so Dr. Seligman, given the plausibility and what you've concluded from this study, is there an immediate policy implication as far as what's going on in Congress right now, with discussions about budget cuts?

  • 13:40:14

    SELIGMANCertainly. The solution that people jump to most quickly is the possibility of administering SNAP, formerly food stamp benefits, twice a month or even weekly rather than once a month, and I urge people to consider that this is a short-sighted policy solution, and the reason why is because many low-income households take a once monthly trip to a geographically distant store in order to stock up on very low cost staple items.

  • 13:40:48

    SELIGMANAnd this trip costs a lot of money usually in transportation costs. If we simply extend benefits week to week or every other week, we eliminate the possibility of people taking this once monthly shopping trip that's a very important coping strategy for people who are living on very limited incomes. That leaves, in my mind, the most obvious strategy which is to simply raise SNAP benefits to a level that they actually can cover people's food needs through the entire month rather than the two to three weeks week of the month that they typically last people nowadays.

  • 13:41:29

    SELIGMANNow, SNAP, the "S" is for "Supplemental." And it's clear that the intention of SNAP benefits is to supplement one's own household food budget. When we do studies, however, in this population, it is clear that for the majority of people who receive SNAP benefits, there is not a household budget that can be devoted to food to supplement that SNAP benefit. And so we really have to be careful in determining what is a SNAP -- a reasonable SNAP benefit to allow people to get to the end of the month.

  • 13:42:03

    FISHERWe have an email from Susan who says, "I’m guessing that it's cheaper and more humane to help people on the front end and make sure they have food and shelter rather than letting them get sick because they don't have enough money for food." And on the superficial level, it's hard to imagine that anyone would disagree with that. On the other hand, politically it's a whole other question entirely, and Leighton Ku, where are we right now in terms of that debate over SNAP, the food stamp -- former food stamp program?

  • 13:42:32

    KUWell, you're right. It's a problem of the way that the Federal government has budgets in silos. So the SNAP budget is one silo, and so it's in the farm bill. And so that's where we fight about that. And obviously we are greatly concerned about health care costs too, and these days anyone's who's watched TV or listened to the radio in the past year realizes that Obamacare has been enormously controversial. And so we are potentially -- we try to reduce spending and the SNAP budget is currently proposed by the House of Representatives, then it's possible that it will inadvertently jack up medical care costs so that not only will there be the human toll that more people are having health problems, but it's going to increase Medicaid costs and other health insurance costs so it really just moves the money around rather than actually saving money.

  • 13:43:25

    FISHERAnd right now Congress is still debating this extension of unemployment insurance. Where does that all stand?

  • 13:43:33

    KUWell, that fits in the same issue. I mean, it's paradoxical. I mean, it's worth telling people. Many people are not aware of this. Actually, benefits in the SNAP program already got reduced by about five percent in the past year. In the Economic Recovery Act a few years ago there was a temporary increase in SNAP benefits because people realized well, gee, when times are hard, people can't find a job, they're going to have more problems buying food, let's raise benefits during this particular time.

  • 13:44:05

    KUThat period expired. Congress chose to not renew that increase. Now they're actually proposing further cuts, particularly aimed at unemployed individuals, people who are having a hard time getting a job. So if you cut off unemployment benefits prematurely, and at the same time take away people's food stamp benefits in that same category, for those individuals, the people who are having a hard time finding work because the economy is still weak where they are at particular time for people with their skills, this creates a real hardship for them.

  • 13:44:39

    FISHERAnd the other -- in addition to the unemployment insurance, there is -- which is -- there's the Farm Bill which includes, as you mentioned, the food assistance program, and that -- the unemployment insurance affected about 1.3 million people, and the food stamp or SNAP program is much larger. So where does that stand, the budget debate there?

  • 13:45:01

    KUWell, it's right now still before Congress. Congress is trying to reconcile House and Senate versions of the Farm Bill, and one of the main sticking points has been cuts in the food stamp program, or the -- I used to be with the Food Nutrition Service many, many years ago, so I still stick with the old name.

  • 13:45:22

    FISHERWell, it's SNAP. They can change the name as many times as they want, people are still going to call it food stamps.

  • 13:45:27

    KUBut anyway, so this is still on the main sticking points. We'll have to see probably in the next few weeks what happens are far as reconciling that. I certainly hope that the information from Dr. Seligman's study is helpful in persuading people why the SNAP benefit cuts really will not only cause hardships for individuals, but potentially are counterproductive because they increase medical care costs.

  • 13:45:52

    FISHERAnd the House Republicans had pushed for a $39 billion cut to that food assistance program whereas the Senate Democrats had proposed a $4 billion cut and at the moment what they're talking about is somewhere in between, about a $9 billion reduction, which I gather would be a pretty substantial one for a lot of people. So we're going to take a short break, but when we come back we'll take some of your calls at 1-800-433-8850, and talk to our guests about the connection between the politics of these budget cuts and the scientific findings of a study that may indicate that it makes sense to not cut the budget but instead go ahead with that spending because the cost of emergency room care is so much higher.

  • 13:46:40

    FISHERAll of that after a short break. I'm Marc Fisher of the Washington post. We'll be back in a moment.

  • 13:48:29

    FISHERWelcome back. I'm Marc Fisher sitting in for Kojo Nnamdi, and we are talking about food assistance and unemployment insurance and the possible impact of budget cuts as well as a new study by one of our guests looking at whether indeed poor people with diabetes are significantly more likely to end up in the hospital for dangerously low blood sugar at the end of the month when budgets are tight. We're talking with Leighton Ku who is a professor at George Washington University School of Public Health and Health Services, and with Hilary Seligman, a professor of medicine at the University of California at San Francisco.

  • 13:49:05

    FISHERAnd Dr. Seligman, in your study you looked at diabetes, and tell us a little bit about how much of the population is affected by diabetes and how this low blood sugar issue pops up for people who are under care for that malady.

  • 13:49:27

    SELIGMANThe reason why this study was really important, I think, for policy implications is that the low-income population in general has a much higher burden of diabetes in general. We know that right now about ten percent of the U.S. low-income population has a diagnosis of diabetes. When you have diabetes, your challenge is to keep your blood sugar in a very narrow window. This is something that the insulin in our body does naturally when we don't have diabetes, keeps our blood sugar level in a very tight range.

  • 13:50:01

    SELIGMANAnd when you have diabetes, you need to take medication to bring your high blood sugars back into the normal range, but make sure that you don't take so much blood sugar -- excuse me, so much medication that you don't overshoot and send your blood sugar into a too low range.

  • 13:50:19

    FISHERAnd so for those who are on that treatment program, how good do you think the health education is around food? Do you think that most of the folks in your study really understand that importance of maintaining that stability?

  • 13:50:39

    SELIGMANYou know, diabetes education is challenging, and we do have inadequate access to diabetes education across the country. That is certainly a problem. But I don't think it's the biggest problem here. I think one of the biggest problems is that health care providers in general don't identify people who are running out of money for food, for a couple of reasons. One is that we have an epidemic of hunger in the United States with one in seven Americans reporting that they worry about running out of money for food. But this is very hidden.

  • 13:51:10

    SELIGMANWe don't talk about this very much. We can't identify people who are food insecure by looking at them, and health care providers have not been taught to screen people for insecurity when they walk in the door. And so we have a situation where it may be unknown to the physicians or the healthcare providers that the patient is struggling with food insecurity and it may be unknown to the patients that when they've run out of money for food they need to reduce their medications.

  • 13:51:39

    SELIGMANNow, one of the things as a physician that I try to teach is that the appropriate response to having a patient who is food insecure and on diabetes medicine is not to lower their medications because that leads to another problem which is that blood sugar goes too high and you end up with complications of diabetes that we're trying to avoid with our medication. Instead what we say is if your blood sugar is going too low because you don't have adequate access to food, we as healthcare providers need to do a better job of identifying that problem and linking you to the hunger safety net.

  • 13:52:14

    SELIGMANHelping you get enrolled in SNAP benefits if you're not enrolled, finding places where you can get food from the hunger safety net such as food pantries, doing nutrition education that is very tailored and targeted to the amount of money that you have. These are much more effective strategies than just lowering medications.

  • 13:52:33

    FISHERLet's hear from Andy in Annandale, Va. Andy, you're on the air.

  • 13:52:37

    ANDYHi, thanks. I just got out of the hospital with a case of food poisoning, and while I was there, I'm an insulin-dependent diabetic by the way, I found that the hospital's policy was to protect themselves rather than protect me against high blood sugar. Now, they're worried about diabetics, you know, running into insulin reactions with low blood sugar, so their policy is to, you know, when they find you have high blood sugar, give you one or two units of insulin for a blood sugar in the 400s and then, you know, check it later and, you know, then adjust.

  • 13:53:28


  • 13:53:28

    ANDYSo they'll leave you a couple hours, maybe even longer, with high blood sugar so that they don't get sued, you know, and instead of doing what a hospital should do which is, you know, having enough staff on hand and paying close attention to your blood sugars, checking it every two hours or something like that.

  • 13:53:46


  • 13:53:46

    ANDYThey'd rather leave your blood sugar go high.

  • 13:53:50

    FISHERDr. Seligman?

  • 13:53:50

    SELIGMANSo that is -- that's an important issue for hospitals and hospital administrators to think about. What it reminds me of is an important point for your listeners, which is that high blood sugar causes problems over the long term, years and years of high blood sugar causes complications. Low blood sugar is very different. Low blood sugar has to be treated immediately and this is why we see this increase in hospitalization at the end of the month.

  • 13:54:21

    SELIGMANIf your blood sugar goes down too low and you don't treat it within minutes to hours, depending on how low it is, then you will very quickly get symptoms, and if not treated, seizures, coma, and death. So low blood sugar reactions in the moment are extremely serious and severe and can be a medical emergency. Similarly with high blood sugar, although you have to be very, very high to cause immediate dangers, we think of high blood sugar as being more of a long-term problem.

  • 13:54:55

    SELIGMANThis is why we were for this study able to take advantage of this end of the month running out of money for food, because we knew that if you ran out of money for food today, you were likely to experience your low blood sugar event that drove you to the hospital today.

  • 13:55:12

    FISHERWe have an email from Jerry in Hagerstown. He says, "While it may sound like the right idea to increase welfare programs to save on emergency room visits, it's really just a band-aid. Our welfare spending is huge, the largest portion of our budget, and yet these issues persist. Part of the problem," Jerry says, "is our healthcare system itself, and you can address the issue you're talking about without looking at the whole picture." Leighton Ku, is there merit to that?

  • 13:55:37

    KUWell, certainly our healthcare spending in the U.S. is huge, and when this particular listener says that our welfare spending is the largest part of our budget, it sort of depends on what you mean. If you include things like Medicare, Social Security, that I don't think most people think of as welfare at all, well, yeah, that's the largest part of our budget. If you begin to think more specifically of things that try to help low-income people and provide sort of daily subsistence like actual cash welfare benefits or the SNAP benefits, then actually we're not spending that much at all relative to what is spent in many other countries.

  • 13:56:12

    KUSo it depends on the perspective. I do think that there are some broader issues that are at hand, that's certainly the case. Nonetheless, this is a very real sort of problem that could be dealt with in a pragmatic way.

  • 13:56:26

    FISHERAnd is there anything in the Affordable Care Act, Obamacare, or the expansion of Medicaid that would help with this issue?

  • 13:56:33

    KUThe expansion of Medicaid helps people to the extent that it means that they can get health insurance so when they go to the emergency room those bills are covered. On the other hand, if they're getting sick, Medicaid does not keep them from getting sick right away. It might eventually get them so that they're talking to a doctor who can help them control their diabetes a little better, but that will take a while for that process to go on. It shifts who's paying for it. It makes that care more humane.

  • 13:57:00

    KUIt makes it so that hospitals can afford to continue to offer services, but it's not going to fix this specific problem in the same sense that having more health insurance is not going to make the common cold go away either.

  • 13:57:14

    FISHERAnd in the remaining seconds...

  • 13:57:15

    SELIGMANThe other thing...`

  • 13:57:16

    FISHERGo ahead.

  • 13:57:17

    SELIGMANThe other thing we have to think about is when you talk about running out of food in a household with children, the long-term health implications of that extend for many, many, many years. Children who go to school hungry and don't have anything to eat have emotional difficulty, intellectual difficulty, cognitive delay. These are things that persist throughout a child's life and make them less likely to reach their intellectual and their employment potential. And this has a huge drag on our economy as well.

  • 13:57:47

    SELIGMANWe have to consider these as healthcare costs and not just the healthcare costs that happen in the immediate time frame of running out of money for food.

  • 13:57:56

    FISHERWe have just a few seconds left. Can I get a yes or no from each of you. Do you think Congress will take this finding into consideration as it makes these budget cuts? Leighton Ku?

  • 13:58:04

    KUI hope so.

  • 13:58:05

    FISHERAnd Dr. Seligman?

  • 13:58:06

    KUI will echo that. I sure hope so.

  • 13:58:09

    FISHERHilary Seligman is a professor of medicine at the University of California at San Francisco, and Leighton Ku is professor of health policy at the School of Public Health and Health Services at George Washington University. Thanks very much to both of you, and thanks to listeners for joining me today. I'm Marc Fisher of the Washington Post.

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