1 00:00:00,650 --> 00:00:02,580 DR. KAREN GLANZ: Good afternoon, everybody. 2 00:00:02,580 --> 00:00:09,070 Welcome to the NIH Workshop on Food Insecurity, Neighborhood Food Environments, and Neighborhood 3 00:00:09,070 --> 00:00:12,540 Health Disparities: The State of the Science. 4 00:00:12,540 --> 00:00:17,970 My name is Karen Glanz from the University of Pennsylvania, and I have the pleasure of 5 00:00:17,970 --> 00:00:22,720 co-chairing this workshop with Angela Odoms-Young from Cornell University. 6 00:00:22,720 --> 00:00:32,710 I want to be sure to encourage everyone to participate in discussions throughout the 7 00:00:32,710 --> 00:00:36,219 workshop by using the chat box feature on the online platform. 8 00:00:36,219 --> 00:00:40,910 We encourage a robust dialogue, so please don’t be shy. 9 00:00:40,910 --> 00:00:46,070 Pose your questions as they come up in the chat box. 10 00:00:46,070 --> 00:00:54,670 We’re thrilled to have so many of you registered for this workshop that will take place over 11 00:00:54,670 --> 00:00:55,670 three days. 12 00:00:55,670 --> 00:01:00,570 Our goal in the workshop is to review the state of the science, identify research gaps 13 00:01:00,570 --> 00:01:06,560 and opportunities, and suggest innovative research strategies that will inform policy 14 00:01:06,560 --> 00:01:13,360 and practice to address and prevent diet-related health disparities and promote health equity. 15 00:01:13,360 --> 00:01:19,049 We look forward to hearing from you as you help us to meet this ambitious goal. 16 00:01:19,049 --> 00:01:25,150 We have more than 40 speakers, a full agenda across three afternoons of the workshop. 17 00:01:25,150 --> 00:01:31,140 Day one will focus on the state of the science in the areas of food insecurity, its health 18 00:01:31,140 --> 00:01:33,650 impacts, and effective interventions. 19 00:01:33,650 --> 00:01:39,280 Tomorrow, on the second day, we will cover research that addresses the neighborhood food 20 00:01:39,280 --> 00:01:42,009 environment and health. 21 00:01:42,009 --> 00:01:48,410 And on the third day, we’ll focus on implementation science, policy, and community-based research 22 00:01:48,410 --> 00:01:57,789 across both areas–what works and what doesn’t. 23 00:01:57,789 --> 00:02:03,300 The overall objectives of this workshop are to describe the current state of research 24 00:02:03,300 --> 00:02:08,370 and gaps and opportunities, to summarize the state of science, and to provide research 25 00:02:08,370 --> 00:02:09,370 suggestions. 26 00:02:09,370 --> 00:02:16,530 As you’ve heard, there are many institutes, centers, and other agencies that have contributed 27 00:02:16,530 --> 00:02:22,900 to planning this workshop and that are eager to hear from both the speakers and the audience 28 00:02:22,900 --> 00:02:30,720 with ideas about how we should be moving forward in the most effective way to make the food 29 00:02:30,720 --> 00:02:38,160 environment as equitable, secure, and healthful for all as possible. 30 00:02:38,160 --> 00:02:47,680 I’m now delighted to introduce Dr. Eliseo J. Pérez-Stable, Director of the National 31 00:02:47,680 --> 00:02:53,480 Institute of Minority Health and Health Disparities, and Deputy Undersecretary Stacy Dean from 32 00:02:53,480 --> 00:02:59,330 USDA’s Food, Nutrition, and Consumer Services, who will provide opening remarks. 33 00:03:05,918 --> 00:03:15,930 DR. ELISEO J. PÉREZ-STABLE: Good afternoon. Good morning. Well, it depends on where you are, and thank you for inviting me to say a few words about 34 00:03:15,930 --> 00:03:18,170 this really critically important topic. 35 00:03:18,170 --> 00:03:25,590 It has received all too little attention in many ways across the NIH. 36 00:03:25,590 --> 00:03:28,769 All right. 37 00:03:28,769 --> 00:03:31,950 I’m the... 38 00:03:31,950 --> 00:03:35,799 I am the Director of the National Institute on Minority Health and Health Disparities, 39 00:03:35,799 --> 00:03:41,120 so in that regard, we’re always concerned about all populations and all aspects of health. 40 00:03:41,120 --> 00:03:49,090 I will share with you some thoughts and general perspectives on health equity as we see them 41 00:03:49,090 --> 00:03:50,670 from NIMHD. 42 00:03:50,670 --> 00:04:01,329 So, some big topics that...I think of as both a clinician-scientist, and Director of NIMHD. 43 00:04:01,329 --> 00:04:07,780 So, measurement in this field has been tedious, and as a not only consumer of the science 44 00:04:07,780 --> 00:04:12,769 but actually working with secondary data analysis when we try to factor in issues around nutrition, 45 00:04:12,769 --> 00:04:17,829 the challenge is, what is in the dataset, and what has been collected? 46 00:04:17,829 --> 00:04:23,240 So, I think this is an area that needs some new thought. 47 00:04:23,240 --> 00:04:28,150 Defining a healthy diet has changed over the years. 48 00:04:28,150 --> 00:04:33,630 Now, you could say we’ve been able to modify and go back or get away from one thing and 49 00:04:33,630 --> 00:04:35,030 go to another. 50 00:04:35,030 --> 00:04:42,320 But this has probably confused our population as the marketing approach to unhealthy diets 51 00:04:42,320 --> 00:04:46,040 has continued without hesitation. 52 00:04:46,040 --> 00:04:54,520 Originally, I think humans were designed really for avoiding undernutrition as we know, and 53 00:04:54,520 --> 00:05:01,290 much of...in some parts of the world, we still face this incredible challenge, but overnutrition 54 00:05:01,290 --> 00:05:07,590 gets very little attention and, in fact, is now the dominant problem that we face as a 55 00:05:07,590 --> 00:05:12,850 society, not just in high-income countries but in most middle-income countries and low-income 56 00:05:12,850 --> 00:05:14,720 countries as well. 57 00:05:14,720 --> 00:05:15,990 Food production is a problem. 58 00:05:15,990 --> 00:05:22,631 I don’t remember the exact number, but over 3,000 calories are produced every day in the 59 00:05:22,631 --> 00:05:28,660 U.S. for consumption, and you all know how many calories we’re supposed to eat on a daily 60 00:05:28,660 --> 00:05:30,979 basis to keep our weight. 61 00:05:30,979 --> 00:05:36,700 So, clearly someone is interested in generating overnutrition in the population. 62 00:05:36,700 --> 00:05:46,410 Less access to healthy foods is really easy… and unhealthy foods is really easy and cheap. 63 00:05:46,410 --> 00:05:53,560 Ultra-processed food, that’s usually what’s marketed, and healthy foods are harder to 64 00:05:53,560 --> 00:05:54,560 obtain. 65 00:05:54,560 --> 00:06:01,960 And then the obesity epidemic and its consequences really has developed during my career. 66 00:06:01,960 --> 00:06:12,100 If I go back to 1980 to where we are in 2021, over these 40 years, you know what has happened. 67 00:06:12,100 --> 00:06:17,630 So, from the context of NIMHD, we focus on populations with health disparities. 68 00:06:17,630 --> 00:06:24,259 The first three bullets in this slide are legislated to us, so all racial and ethnic 69 00:06:24,259 --> 00:06:30,730 minorities as defined by the U.S. Census, all poor people of any color, and then underserved 70 00:06:30,730 --> 00:06:32,039 rural residents. 71 00:06:32,039 --> 00:06:38,980 In 2016, we declared sexual and gender minorities as a population with health disparities for 72 00:06:38,980 --> 00:06:45,569 NIH research purposes, and I think it has triggered a number of changes in how we consider 73 00:06:45,569 --> 00:06:49,030 this population and collect data. 74 00:06:49,030 --> 00:06:55,349 We endorse the idea that social disadvantage, that it results in part from being subject 75 00:06:55,349 --> 00:07:02,310 to discrimination or racism and from being underserved in health care is a unifying factor 76 00:07:02,310 --> 00:07:04,970 for all of these populations with health disparities. 77 00:07:04,970 --> 00:07:10,009 And then a health outcome that is worse in one of these populations compared to a reference 78 00:07:10,009 --> 00:07:14,030 group defined, in our view, a health disparity. 79 00:07:14,030 --> 00:07:21,919 We also start with the premise that race/ethnicity as a social construct, a self-identified social 80 00:07:21,919 --> 00:07:28,530 construct, and socioeconomic status or social class are fundamental in determining health. 81 00:07:28,530 --> 00:07:33,660 It has to be proven otherwise that they don’t matter before you don’t measure them or 82 00:07:33,660 --> 00:07:35,060 don’t consider them. 83 00:07:35,060 --> 00:07:40,740 And I think this is a paradigm shift for many clinicians-scientists who have not worked 84 00:07:40,740 --> 00:07:44,900 in populations or community engagement or in disparities research. 85 00:07:44,900 --> 00:07:50,830 Race/ethnicity and SES predict so many things like life expectancy, total mortality, that 86 00:07:50,830 --> 00:07:53,620 are not really fully explained or understood. 87 00:07:53,620 --> 00:07:58,759 African Americans, for example, have more strokes when compared to whites for the same 88 00:07:58,759 --> 00:08:03,729 exact level of systolic blood pressure, and the hazard ratio is two. 89 00:08:03,729 --> 00:08:07,400 Most chronic diseases are more common in persons who are poor. 90 00:08:07,400 --> 00:08:11,130 And again, it’s not only because of poor behavior. 91 00:08:11,130 --> 00:08:17,490 And then among persons with diabetes, all racial and ethnic minorities compared to whites 92 00:08:17,490 --> 00:08:24,759 have less heart disease and more end-stage renal disease over a 10-year prospective registry 93 00:08:24,759 --> 00:08:27,790 follow-up in the Kaiser Permanente of Northern California. 94 00:08:27,790 --> 00:08:34,099 Again, this doesn’t have explanations, so we often just don’t talk about it as much. 95 00:08:34,099 --> 00:08:40,519 This is data from the CDC published several years ago, illustrating the importance of 96 00:08:40,519 --> 00:08:44,200 using both race/ethnicity and socioeconomic status. 97 00:08:44,200 --> 00:08:52,050 It shows the rate of...the prevalence of obesity among youth by the education level of the 98 00:08:52,050 --> 00:08:53,460 head of the household. 99 00:08:53,460 --> 00:08:57,769 And I’m trying to contrast the lowest level of education of the head of household, so 100 00:08:57,769 --> 00:09:01,480 less than high school, with some college. 101 00:09:01,480 --> 00:09:07,120 And you can see there is a clear-cut SES gradient in the prevalence of obesity among the youth 102 00:09:07,120 --> 00:09:10,890 living in this household in all racial and ethnic groups. 103 00:09:10,890 --> 00:09:18,089 We also can see that for Blacks and Latinos, it is much higher, to begin with, for those 104 00:09:18,089 --> 00:09:22,730 head of households/homes with less than high school for the head of household. 105 00:09:22,730 --> 00:09:28,570 And the benefit from having some college, although present, is not as marked as it is 106 00:09:28,570 --> 00:09:29,760 for whites. 107 00:09:29,760 --> 00:09:33,320 And so, this is more research that’s needed this way. 108 00:09:33,320 --> 00:09:34,320 We need to stratify. 109 00:09:34,320 --> 00:09:35,500 We need to look at both. 110 00:09:35,500 --> 00:09:42,700 They’re not mutually exclusive, nor are they fully explaining each other’s findings. 111 00:09:42,700 --> 00:09:49,040 In NIMHD, we have focused with standardized measurements of social determinants of health 112 00:09:49,040 --> 00:09:52,060 over about the past 3.5 to 4 years. 113 00:09:52,060 --> 00:09:58,910 So, structural social determinants of health, so things that are not measured by individual 114 00:09:58,910 --> 00:10:02,029 respondents, some of them are listed here. 115 00:10:02,029 --> 00:10:08,840 Of course, you see access to healthy and affordable food here, the topic of this workshop, one 116 00:10:08,840 --> 00:10:12,029 of the topics of this workshop, as well as green space and sidewalks. 117 00:10:12,029 --> 00:10:14,930 So, I think that you can get a sense. 118 00:10:14,930 --> 00:10:21,160 We have created a website on the PHENX Toolkit website that the NIH has. 119 00:10:21,160 --> 00:10:27,060 Our logo here, the three colored houses in the bottom corner, with measures that we have 120 00:10:27,060 --> 00:10:32,110 vetted through the PHENX process with an expert external panel. 121 00:10:32,110 --> 00:10:36,950 We completed one phase and launched this in May of 2020. 122 00:10:36,950 --> 00:10:41,269 We are now about to start a second phase where a lot of the measures we’re going to look 123 00:10:41,269 --> 00:10:44,160 at are primarily structural social determinants. 124 00:10:44,160 --> 00:10:53,340 NIMHD also has a framework that we’ve published, now almost three years ago, developed by staff 125 00:10:53,340 --> 00:10:56,470 on prompting whi I arrived. 126 00:10:56,470 --> 00:11:01,251 And as you can see, it is multiple levels of influence, not only going from the individual 127 00:11:01,251 --> 00:11:10,399 to societal, and from the biological and behavioral over here to the health care system and all 128 00:11:10,399 --> 00:11:15,260 the health outcomes that these relate to. 129 00:11:15,260 --> 00:11:18,170 We use the framework for guiding our work. 130 00:11:18,170 --> 00:11:23,389 Most of our funding continues to still be in this first column, the individual, but 131 00:11:23,389 --> 00:11:28,920 we are certainly striving to expand those dimensions. 132 00:11:28,920 --> 00:11:32,589 And let me just end with a couple of data points. 133 00:11:32,589 --> 00:11:40,300 This is about racism, and just to put it on the table, it affects how–these are data 134 00:11:40,300 --> 00:11:45,771 from the Kaiser Family Foundation published about 5 years ago–and that over a third of 135 00:11:45,771 --> 00:11:52,331 Latinos and over a half of African-Americans agreed with the statement that in the past 136 00:11:52,331 --> 00:11:57,370 30 days, they were treated unfairly because of racial and ethnic background in store 137 00:11:57,370 --> 00:11:59,100 or work. 138 00:11:59,100 --> 00:12:02,310 And this, I think, cannot be ignored. 139 00:12:02,310 --> 00:12:07,690 Past 30 days, not the lifetime, not the last year, past 30 days. 140 00:12:07,690 --> 00:12:11,380 Racism is alive and well in our country. 141 00:12:11,380 --> 00:12:19,810 These are data from a while back to illustrate the rates of food security among Americans 142 00:12:19,810 --> 00:12:23,639 by race/ethnicity, as well as educational level. 143 00:12:23,639 --> 00:12:31,579 And you can see that Latinos and African-Americans have about a 70...65...70 percent 144 00:12:31,579 --> 00:12:33,110 rate of food security. 145 00:12:33,110 --> 00:12:38,060 And looking at more recent data, these numbers are probably not quite this low. 146 00:12:38,060 --> 00:12:44,000 They’re probably closer to 80 percent, but they’re still about 10,15 percentage points 147 00:12:44,000 --> 00:12:48,370 below what white Americans have in terms of food security. 148 00:12:48,370 --> 00:12:57,410 But the gradient by educational level is more dramatic, with over 90 percent of college 149 00:12:57,410 --> 00:13:03,700 graduates feeling secure compared to 60 percent of those with less than high school. 150 00:13:03,700 --> 00:13:09,529 And then a couple of studies funded by NIMHD, this is a trend in consumption of ultra-processed 151 00:13:09,529 --> 00:13:12,040 foods among youth. 152 00:13:12,040 --> 00:13:21,350 I found this quite striking that over the course of these, what is not quite 20 years 153 00:13:21,350 --> 00:13:29,130 or so, using multiple cross-sectional data from the NHANES unprocessed ultra-processed 154 00:13:29,130 --> 00:13:30,940 foods went up. 155 00:13:30,940 --> 00:13:38,750 And the biggest increase...and they went up in all groups, all educational groups, all 156 00:13:38,750 --> 00:13:41,620 race and ethnic groups, it didn’t matter. 157 00:13:41,620 --> 00:13:46,200 Ultra-processed foods accounted for greater increases in calories in Black and Mexican 158 00:13:46,200 --> 00:13:47,200 youth. 159 00:13:47,200 --> 00:13:54,200 But it went up in everyone, and it went from a total of ultra-processed foods and ready-to-heat-and-eat 160 00:13:54,200 --> 00:14:03,310 dishes, which accounted for about 11 percent of daily calories, as opposed to 2 percent. 161 00:14:03,310 --> 00:14:07,880 We have a problem. 162 00:14:07,880 --> 00:14:14,340 And then this is a cool study that is yet to evaluate all the outcomes. 163 00:14:14,340 --> 00:14:20,949 The Navajo Nation, with an R01-funded and supported in part by an R01 that we funded through the 164 00:14:20,949 --> 00:14:25,329 Tribal Epidemiology Center there, extended their 2 percent junk food tax. 165 00:14:25,329 --> 00:14:36,980 It is the first such tax in the U.S. or in sovereign Tribal nations, and it has led to a generation 166 00:14:36,980 --> 00:14:38,830 of revenue. 167 00:14:38,830 --> 00:14:44,000 We hope that it will also lead to a decrease in junk food consumption. 168 00:14:44,000 --> 00:15:03,450 Thank you very much for your attention, and I think I’ll turn it back to Karen. 169 00:15:03,450 --> 00:15:04,450 DR. STACY DEAN: Good afternoon. 170 00:15:04,450 --> 00:15:08,920 I’m Stacy Dean, USDA’s Deputy Undersecretary for Food, Nutrition, and Consumer Services. 171 00:15:08,920 --> 00:15:11,310 USDA is honored to be a part of this event. 172 00:15:11,310 --> 00:15:16,060 Thank you to NIH for hosting and to all of you for your interest in this important topic. 173 00:15:16,060 --> 00:15:21,839 Though we can’t be physically together, it’s still inspiring to be in community 174 00:15:21,839 --> 00:15:25,690 with others who are dedicated to the cause of combating food insecurity and diet-related 175 00:15:25,690 --> 00:15:26,690 disparity. 176 00:15:26,690 --> 00:15:29,500 I can’t imagine a more relevant time for these discussions. 177 00:15:29,500 --> 00:15:34,889 The pandemic has placed unprecedented stress on American families, leaving in its wake 178 00:15:34,889 --> 00:15:38,170 millions struggling to make ends meet and put food on the table. 179 00:15:38,170 --> 00:15:44,570 The latest census data show that 17 million adults, one in 13, reported not having enough 180 00:15:44,570 --> 00:15:50,830 food to eat, and the crisis of food insecurity is particularly acute in communities of color. 181 00:15:50,830 --> 00:15:56,220 Today, about one in seven Black and one in eight Latino adults live in food-insecure 182 00:15:56,220 --> 00:15:57,220 households. 183 00:15:57,220 --> 00:16:02,870 Compare this with the one in 12 white non-Hispanic adults living in food insecurity, and you 184 00:16:02,870 --> 00:16:06,610 quickly see the stark inequity in disparity. 185 00:16:06,610 --> 00:16:11,120 Families with kids are also more likely to struggle, leaving far too many parents with 186 00:16:11,120 --> 00:16:16,690 the impossible decision of having to choose between serving less to their family or skipping 187 00:16:16,690 --> 00:16:17,690 meals themselves. 188 00:16:17,690 --> 00:16:22,360 We hear those statistics, and we see people in need all around us every single day, but 189 00:16:22,360 --> 00:16:27,071 sometimes we forget to stop and take a moment to really acknowledge and reflect on the impact 190 00:16:27,071 --> 00:16:28,430 this pandemic has had on all of us. 191 00:16:28,430 --> 00:16:34,000 This has been and continues to be a scary and uncertain time, and we’re going to be 192 00:16:34,000 --> 00:16:37,089 dealing with the impacts of that for years to come. 193 00:16:37,089 --> 00:16:43,000 But amidst that uncertainty, we also have the opportunity to learn from our collective 194 00:16:43,000 --> 00:16:48,380 experience, both to help those in need now and better serve them going forward. 195 00:16:48,380 --> 00:16:53,020 The Biden administration has a goal to build back better, to come out the other end of 196 00:16:53,020 --> 00:16:56,730 this pandemic in a better place than where we began. 197 00:16:56,730 --> 00:17:00,900 For USDA’s Food and Nutrition Service, that means we’re going to strengthen our programs 198 00:17:00,900 --> 00:17:08,699 and remove barriers to make sure all families have a reliable food safety net, one that 199 00:17:08,699 --> 00:17:14,500 promotes not only food security but also nutrition security, the idea that all people at all 200 00:17:14,500 --> 00:17:17,910 times have access to a healthy diet. 201 00:17:17,910 --> 00:17:24,209 Nutrition insecurity is a complex challenge, and one with lasting negative consequences. 202 00:17:24,209 --> 00:17:26,749 For example, today one-fifth of American children are obese. 203 00:17:26,749 --> 00:17:31,820 Not surprisingly, research shows this increases the likelihood of obesity in adulthood, creating 204 00:17:31,820 --> 00:17:37,590 financial strains on families, our health care system, and our ability to remain safe 205 00:17:37,590 --> 00:17:39,740 and secure as a nation. 206 00:17:39,740 --> 00:17:41,650 USDA’s Nutrition Assistance programs can help. 207 00:17:41,650 --> 00:17:47,110 They are some of the most far-reaching powerful tools available to ensure that all Americans 208 00:17:47,110 --> 00:17:51,730 have access to a healthy diet, and their need has never been felt so urgently. 209 00:17:51,730 --> 00:17:57,190 I know you’ll be hearing more from Dr. Melissa Abelev on the specifics of these programs 210 00:17:57,190 --> 00:18:01,600 and how we intend to move forward in the coming months and years. 211 00:18:01,600 --> 00:18:07,429 Yet, we have a lot of work ahead to ensure that programs serve everyone evenly and fairly. 212 00:18:07,429 --> 00:18:12,230 Nutrition and security, like food insecurity, disproportionately burden low-income families, 213 00:18:12,230 --> 00:18:16,030 especially those in communities of color. 214 00:18:16,030 --> 00:18:19,340 Black, Latino, Native American, as well as people living in rural low-income counties, 215 00:18:19,340 --> 00:18:24,770 suffer the greatest disparities with regard to nutritional quality and corresponding diet-related 216 00:18:24,770 --> 00:18:25,770 disease. 217 00:18:25,770 --> 00:18:30,789 We cannot combat food and nutrition insecurity without acknowledging and committing to break 218 00:18:30,789 --> 00:18:33,250 down the cycle of racial inequity at play. 219 00:18:33,250 --> 00:18:37,570 We need to tackle inequities in our programs while offering a constructive voice in the 220 00:18:37,570 --> 00:18:41,020 racial justice conversation. 221 00:18:41,020 --> 00:18:44,140 In the Biden administration, this is central to our approach. 222 00:18:44,140 --> 00:18:49,549 We’re working to bake it into everything we do and everything we set out to accomplish, 223 00:18:49,549 --> 00:18:51,820 and I believe it starts with listening. 224 00:18:51,820 --> 00:18:56,780 We must spend more time with those with lived experiences of our programs, both participating 225 00:18:56,780 --> 00:19:03,299 in and operating them to ensure what we do and how we do it is helping those who rely 226 00:19:03,299 --> 00:19:04,320 on our services. 227 00:19:04,320 --> 00:19:09,850 We must also expand the roster of who we’re listening to, finding those who engage with 228 00:19:09,850 --> 00:19:15,000 or are impacted by and rely on our programs and using their experience to guide our next steps. 229 00:19:15,000 --> 00:19:19,294 That’s how we’ll make strides in fighting food and nutrition insecurity. 230 00:19:19,294 --> 00:19:24,630 That’s how we’ll start to close the disparities, and it’s how we will build back better. 231 00:19:24,630 --> 00:19:29,210 During this workshop, you’ll get to hear more of the specifics about the federal response 232 00:19:29,210 --> 00:19:33,260 to hunger, and I know my colleague, Melissa for one, will be sharing more about what we’re 233 00:19:33,260 --> 00:19:38,990 actually doing at the Food and Nutrition Service to put these promises into action. 234 00:19:38,990 --> 00:19:44,169 She’ll talk about WIC, child nutrition, SNAP education, amongst other things, as 235 00:19:44,169 --> 00:19:47,180 key components to addressing nutrition insecurity. 236 00:19:47,180 --> 00:19:52,500 But I want to emphasize again that we are open to listening and hearing from you as 237 00:19:52,500 --> 00:19:53,500 well. 238 00:19:53,500 --> 00:19:55,090 You can be partners in this effort. 239 00:19:55,090 --> 00:19:59,810 You have valuable perspectives and expertise, and we invite you to share those with us. 240 00:19:59,810 --> 00:20:01,700 We want to be in evidence. 241 00:20:01,700 --> 00:20:03,910 We want our policymaking to be evidence-based. 242 00:20:03,910 --> 00:20:06,289 Our nation’s families are counting on us. 243 00:20:06,289 --> 00:20:08,480 So, let’s not wait any longer. 244 00:20:08,480 --> 00:20:10,270 Let’s build back better. 245 00:20:10,270 --> 00:20:22,250 Thank you and enjoy the workshop. 246 00:20:22,250 --> 00:20:31,080 DR. ANGELA ODOMS-YOUNG: Thank you so much to our opening speakers. 247 00:20:31,080 --> 00:20:35,090 As Karen mentioned, my name is Angela Odoms-Young. 248 00:20:35,090 --> 00:20:40,630 I’m an Associate Professor in the Division of Nutritional Sciences at Cornell University, 249 00:20:40,630 --> 00:20:43,500 and I serve as a co-chair for this workshop. 250 00:20:43,500 --> 00:20:47,700 I’m very excited to introduce Session 1. 251 00:20:47,700 --> 00:20:54,270 The focus of Session 1 is really to provide an overview and the definitions, measurement, 252 00:20:54,270 --> 00:20:58,780 and also the federal programs that are here to address food insecurity. 253 00:20:58,780 --> 00:21:03,820 So, the objectives of the session, we plan to describe food insecurity and its growing 254 00:21:03,820 --> 00:21:09,980 trends in the U.S., discuss how food insecurity is measured, really dig into the key lessons 255 00:21:09,980 --> 00:21:16,710 from the 25 years of food insecurity measurement, identify gaps in knowledge and research opportunities 256 00:21:16,710 --> 00:21:21,860 in the area of food insecurity, and describe how food insecurity is addressed through federal 257 00:21:21,860 --> 00:21:28,380 safety net programs in the U.S., as was mentioned during the opening. 258 00:21:28,380 --> 00:21:33,110 So, we have three speakers for this session. 259 00:21:33,110 --> 00:21:38,820 Our first speaker will provide an overview of food insecurity and food and nutrition 260 00:21:38,820 --> 00:21:40,610 service programs. 261 00:21:40,610 --> 00:21:46,059 And we have Melissa Abelev from the Food and Nutrition Service in the United States Department 262 00:21:46,059 --> 00:21:47,750 of Agriculture. 263 00:21:47,750 --> 00:21:53,840 We will have an overview of food insecurity measurement by Dr. Alisha Coleman-Jensen from 264 00:21:53,840 --> 00:21:58,750 the Economic Research Service in the United States Department of Agriculture. 265 00:21:58,750 --> 00:22:05,250 And then Dr. Sheri Weiser from–a professor in medicine at the University of California, 266 00:22:05,250 --> 00:22:12,919 San Francisco–will talk about the pathophysiology linking food insecurity with obesity and 267 00:22:12,919 --> 00:22:13,990 cardiometabolic diseases. 268 00:22:13,990 --> 00:22:20,429 So, we’re going to start our session with Dr. Abelev from the Food and Nutrition Service 269 00:22:20,429 --> 00:22:22,570 at the USDA. 270 00:22:22,570 --> 00:22:29,690 DR. MELISSA ABELEV: Hello, everyone. 271 00:22:29,690 --> 00:22:31,909 I’m Melissa Abelev. 272 00:22:31,909 --> 00:22:36,990 I’m the Assistant Deputy Administrator for Policy Support at USDA’s Food and Nutrition 273 00:22:36,990 --> 00:22:37,990 Service. 274 00:22:37,990 --> 00:22:44,990 I was asked today to provide an overview of food insecurity and the FNS programs. 275 00:22:44,990 --> 00:22:51,039 And so, I want to talk about what our programs are, why they’re important, how we responded 276 00:22:51,039 --> 00:22:57,730 to COVID, and then provide a definition of nutrition security, which is an administration 277 00:22:57,730 --> 00:23:04,100 priority, and how this is different than food security, in general and what we’re doing 278 00:23:04,100 --> 00:23:07,720 in the nutrition security space and what we’re focusing on next. 279 00:23:07,720 --> 00:23:10,510 So, first, what are FNS’s programs? 280 00:23:10,510 --> 00:23:19,370 Most simplistically, they’re the federal response to hunger in this country. 281 00:23:19,370 --> 00:23:23,510 FNS administers about 15 different nutrition assistance programs, the largest of which 282 00:23:23,510 --> 00:23:28,369 is the Supplemental Nutrition Assistance Program, or SNAP, commonly known as food stamps. 283 00:23:28,369 --> 00:23:34,340 The next largest group of programs are the child nutrition programs. 284 00:23:34,340 --> 00:23:38,539 Most people are probably familiar with school breakfast and school lunch. 285 00:23:38,539 --> 00:23:44,630 We also have the Child and Adult Daycare Program, which serves about 4 million people each day, 286 00:23:44,630 --> 00:23:52,720 The Summer Food Service Program, which is for when schools are not in session so that 287 00:23:52,720 --> 00:23:54,750 children in need can still get access to meals, a smaller program called the Fresh Fruit and 288 00:23:54,750 --> 00:24:00,500 Vegetable Program, which is targeted towards schools in low-income neighborhoods so that 289 00:24:00,500 --> 00:24:05,330 they can get snacks outside of the regular meal service time of fresh fruits and vegetables, 290 00:24:05,330 --> 00:24:10,809 and then the Special Milk Program, which provides milk to schools that are not providing the 291 00:24:10,809 --> 00:24:11,910 National School Lunch Program. 292 00:24:11,910 --> 00:24:18,720 The Women, Infants and Children program is targeted towards pregnant and postpartum 293 00:24:18,720 --> 00:24:23,540 women, as well as infants and children through their fifth birthday who were at nutrition 294 00:24:23,540 --> 00:24:24,540 risk. 295 00:24:24,540 --> 00:24:31,940 It provides a food prescription, which is a specific list of foods that people can buy 296 00:24:31,940 --> 00:24:38,590 at the grocery store that are targeted towards addressing this specific nutrition risks of 297 00:24:38,590 --> 00:24:40,330 those groups. 298 00:24:40,330 --> 00:24:46,290 We also have some Small Farmers Market programs that provide funds for people to purchase 299 00:24:46,290 --> 00:24:49,450 things at participating farmers markets. 300 00:24:49,450 --> 00:24:54,790 And then the last group of programs are our Food Distribution programs, which is where 301 00:24:54,790 --> 00:25:00,740 USDA is actually purchasing food commodities and then distributing them through our partners, 302 00:25:00,740 --> 00:25:08,130 including the Emergency Food Assistance program, the Food Distribution program on Indian reservations, 303 00:25:08,130 --> 00:25:12,419 the Commodity Supplemental Food program, which is targeted towards the elderly, and then 304 00:25:12,419 --> 00:25:14,179 USDA Foods and Schools. 305 00:25:14,179 --> 00:25:20,770 That last one is the reimbursement that schools get for participating in National School Lunch 306 00:25:20,770 --> 00:25:26,590 and School Breakfast, comes through a combination of cash reimbursements, as well as the ability 307 00:25:26,590 --> 00:25:31,000 to make purchases of USDA Foods for about 20 percent of their reimbursement. 308 00:25:31,000 --> 00:25:42,592 And so, they can benefit from the buying power of USDA and purchase commodity foods in that way. 309 00:25:42,592 --> 00:25:49,980 So, now that we’ve talked about what the programs are, let’s go over a little bit 310 00:25:49,980 --> 00:25:51,730 about why our programs are important. 311 00:25:51,730 --> 00:25:58,590 I want to present some data from the census department’s pulse survey. 312 00:25:58,590 --> 00:26:00,770 And that data is about food insufficiency. 313 00:26:00,770 --> 00:26:08,080 I do want to note that my colleague at USDA, Alisha Coleman-Jensen is speaking after me. 314 00:26:08,080 --> 00:26:15,080 s\She is going to be describing food security, which is a validated measure; that USDA collects 315 00:26:15,080 --> 00:26:19,980 once a year, every year and has for about 25 years. 316 00:26:19,980 --> 00:26:27,020 What the pulse survey did was not the validated measure, they asked just a couple of questions. 317 00:26:27,020 --> 00:26:31,430 And so, it’s really not providing solid data on food security. 318 00:26:31,430 --> 00:26:35,490 What it’s doing is looking at food insufficiency. 319 00:26:35,490 --> 00:26:41,500 And it’s better to really considered the results of that data more as trends than as 320 00:26:41,500 --> 00:26:42,570 specific point estimates. 321 00:26:42,570 --> 00:26:47,340 And so, there’s some differences in the data that I’ll present and what Alisha will 322 00:26:47,340 --> 00:26:48,340 present. 323 00:26:48,340 --> 00:26:54,720 But I think what the pulse survey does is it really provides trends that you can think 324 00:26:54,720 --> 00:27:00,140 of over time, and a particular snapshot specific to the pandemic time. 325 00:27:00,140 --> 00:27:05,970 So, with that caveat, let me present a little bit about what we were seeing. 326 00:27:05,970 --> 00:27:12,429 So, we know that even outside of the pandemic, food insecurity is a real challenge for millions 327 00:27:12,429 --> 00:27:14,500 of American families. 328 00:27:14,500 --> 00:27:19,480 Throughout the pandemic, it continued to be a challenge, and it remains so now. 329 00:27:19,480 --> 00:27:24,960 Although what we can see in this chart, which is showing the food insufficiency rates over 330 00:27:24,960 --> 00:27:30,539 the course of the entire pandemic, is that the rates do seem to be declining, and we’re 331 00:27:30,539 --> 00:27:37,799 at the lowest in the last data collection in August, as they were in the entire pandemic. 332 00:27:37,799 --> 00:27:42,760 A couple of things are important here, the Biden administration is really focusing on 333 00:27:42,760 --> 00:27:46,429 ensuring that we’re looking at our programs through a racial equity lens. 334 00:27:46,429 --> 00:27:55,390 And so, really looking at: are programs affecting people of different groups in different ways? 335 00:27:55,390 --> 00:28:00,940 This graph doesn’t show the effect of our programs per se, but it does look at how different 336 00:28:00,940 --> 00:28:03,390 groups are experiencing food insufficiency. 337 00:28:03,390 --> 00:28:08,730 So, the gray line, which is the second from the bottom, is if you look at all of the data 338 00:28:08,730 --> 00:28:14,140 together, if you separate it out though by racial group, then you can see that while 339 00:28:14,140 --> 00:28:20,280 white families are struggling, their struggle is less severe than black and Hispanic families. 340 00:28:20,280 --> 00:28:27,990 And so, what you see is that, about one in eight Latino families were experiencing food 341 00:28:27,990 --> 00:28:34,740 insufficiency or reporting food insufficiency in the last seven days, in the last data collection. 342 00:28:34,740 --> 00:28:37,630 For Black families, that’s one in seven. 343 00:28:37,630 --> 00:28:42,840 And for white families, that’s one in 18. 344 00:28:42,840 --> 00:28:47,000 Further what the data show us for families with children; is that they are reporting 345 00:28:47,000 --> 00:28:53,220 food insufficiency 45 percent more frequently than households without children. 346 00:28:53,220 --> 00:28:58,679 So, you see on there, the blue line is households without children, the red line is households 347 00:28:58,679 --> 00:29:00,519 with children. 348 00:29:00,519 --> 00:29:07,620 The data also indicate that the initiatives we’ve implemented for schools have been 349 00:29:07,620 --> 00:29:12,399 a very important source of food assistance for families with children. 350 00:29:12,399 --> 00:29:19,320 We see that the pandemic EBT, which I’ll describe later, was a key resource for families 351 00:29:19,320 --> 00:29:25,529 with children, as were the grab and go meals, which were both initiatives FNS had to pivot 352 00:29:25,529 --> 00:29:28,679 to once the crisis started. 353 00:29:28,679 --> 00:29:35,299 So, with that data in mind, let’s talk about FNS’s response to COVID. 354 00:29:35,299 --> 00:29:41,260 As everything began shutting down in March 2020, because of the pandemic, FNS had to 355 00:29:41,260 --> 00:29:45,840 pivot pretty quickly to ensure that our programs were still responding to the need. 356 00:29:45,840 --> 00:29:53,070 We issued over 800 different flexibilities and waivers over the course of the pandemic 357 00:29:53,070 --> 00:29:58,010 and continue to extend them as needed in order to make sure that our programs are serving 358 00:29:58,010 --> 00:29:59,010 those in need. 359 00:29:59,010 --> 00:30:04,950 In SNAP, the key changes were increasing the benefit amounts through emergency allotments 360 00:30:04,950 --> 00:30:10,179 and a 15 percent increase so that families had more resources to purchase groceries. 361 00:30:10,179 --> 00:30:15,269 In the Child Nutrition programs and in WIC, those programs actually have requirements 362 00:30:15,269 --> 00:30:19,539 for face-to-face in-person for certain aspects of the program. 363 00:30:19,539 --> 00:30:24,730 So, one of the key things that we did was remove that requirement for the two programs... 364 00:30:24,730 --> 00:30:27,300 or the two types of programs. 365 00:30:27,300 --> 00:30:33,100 And for Child Nutrition programs, we created grab and go options so that schools could 366 00:30:33,100 --> 00:30:38,490 distribute multiple meals at a time and that parents could pick them up and took away the 367 00:30:38,490 --> 00:30:40,910 requirement that children had to pick them up. 368 00:30:40,910 --> 00:30:48,720 We also established the pandemic EBT program, which either on an existing SNAP card or by 369 00:30:48,720 --> 00:30:54,380 distributing a new EBT card to any child in the household who was eligible for free and 370 00:30:54,380 --> 00:30:58,350 reduced price lunch, and then it was expanded to the CACFP program. 371 00:30:58,350 --> 00:31:05,539 But you could get up to $6.82 per child, per day on that EBT card that could then be used 372 00:31:05,539 --> 00:31:09,950 like a SNAP card for purchasing groceries at the grocery store. 373 00:31:09,950 --> 00:31:16,470 In the Food Distribution program, we got additional funds to be able to distribute to our local 374 00:31:16,470 --> 00:31:17,470 partners. 375 00:31:17,470 --> 00:31:23,860 In the TEFAP program, we made some changes with disaster household distribution, so that 376 00:31:23,860 --> 00:31:25,610 things could get to people faster. 377 00:31:25,610 --> 00:31:31,669 And there was additional funding in the FDPIR, as well. 378 00:31:31,669 --> 00:31:38,360 As I mentioned upfront, there’s food security, but there’s also nutrition security, which 379 00:31:38,360 --> 00:31:41,559 is a Biden administration and Secretary Vilsack priority. 380 00:31:41,559 --> 00:31:47,179 And so, many have asked what is nutrition security? 381 00:31:47,179 --> 00:31:53,610 Nutrition security is really ensuring that people have, at all times, access to nutritious 382 00:31:53,610 --> 00:31:57,200 foods to support a healthy and active life. 383 00:31:57,200 --> 00:32:04,659 So, that’s a long quote, but in sum, it’s really looking at access to nutritious food. 384 00:32:04,659 --> 00:32:10,730 So, I’ll talk a little bit about those two capitalized words but access is ensuring 385 00:32:10,730 --> 00:32:17,299 that everybody knows of the program, if they’re eligible, how long they’re eligible, and 386 00:32:17,299 --> 00:32:22,490 that people of different racial groups are not getting differential access, but that 387 00:32:22,490 --> 00:32:28,320 instead, we’re ensuring that the programs are implemented and designed in a way that 388 00:32:28,320 --> 00:32:32,299 people who are eligible for them can access them easily. 389 00:32:32,299 --> 00:32:37,340 We also want to make sure that folks are not simply able to get food but that they’re 390 00:32:37,340 --> 00:32:42,740 able to get nutritious food, and that they have the nutrition education and resources 391 00:32:42,740 --> 00:32:48,169 to know how to purchase and prepare nutritious foods to support a healthy life. 392 00:32:48,169 --> 00:32:56,400 What are FNS’s programs focusing on in order to support nutrition security? 393 00:32:56,400 --> 00:33:03,419 FNS is taking a number of actions in order to ensure access to nutritious food. 394 00:33:03,419 --> 00:33:08,950 One of the largest activities we’re working on is the WIC 390 Innovations Fund. 395 00:33:08,950 --> 00:33:15,990 The American Rescue Plan Act provided FNS with $390 million over the next few years 396 00:33:15,990 --> 00:33:23,000 to develop innovative outreach strategies, modernize the program and include waivers 397 00:33:23,000 --> 00:33:29,410 and flexibility to pilot some new approaches aimed at increasing participation and redemption 398 00:33:29,410 --> 00:33:32,470 of benefits. 399 00:33:32,470 --> 00:33:37,299 Participation in WIC declines pretty substantially after the first birthday, even though children 400 00:33:37,299 --> 00:33:40,030 are eligible up through their fifth birthday. 401 00:33:40,030 --> 00:33:46,279 And so, part of the focus of this fund is really ensuring that WIC participants know 402 00:33:46,279 --> 00:33:52,080 of their continued eligibility and that the program is designed in such a way that access 403 00:33:52,080 --> 00:33:58,650 is simple, it’s not cumbersome, and it’s something that participants can really access 404 00:33:58,650 --> 00:34:04,150 the benefits that are really targeted towards their nutrition risk so that we can continue 405 00:34:04,150 --> 00:34:06,240 to improve this public health program. 406 00:34:06,240 --> 00:34:12,510 We are doing that, in part, through learning from the SNAP online purchasing pilot which 407 00:34:12,510 --> 00:34:18,099 was expanded substantially during the pandemic, from a small pilot in about six 408 00:34:18,099 --> 00:34:25,210 cities, to now where almost 94 percent of SNAP participants have access to online purchasing. 409 00:34:25,210 --> 00:34:30,619 We will be learning from those lessons and developing a WIC online purchasing program 410 00:34:30,619 --> 00:34:31,619 as well. 411 00:34:31,619 --> 00:34:37,660 We’re also updating the WIC food package rule based on a NASEM review, which is the National 412 00:34:37,660 --> 00:34:44,580 Academies of Sciences review that was conducted a few years ago, as well as the updated Dietary 413 00:34:44,580 --> 00:34:46,339 Guidelines for Americans. 414 00:34:46,339 --> 00:34:52,179 The latest report which was published in December of 2020, included for the first time, standards 415 00:34:52,179 --> 00:34:55,700 for pregnant women and children under the age of two. 416 00:34:55,700 --> 00:35:00,410 So, using those science-based guidance documents, we will be updating the WIC food package rule 417 00:35:00,410 --> 00:35:02,520 to ensure nutritious food. 418 00:35:02,520 --> 00:35:07,369 We’re also looking further at the child nutrition meal standards for School Lunch, 419 00:35:07,369 --> 00:35:11,940 School Breakfast and CACFP to ensure that they are aligning with the Dietary Guidelines 420 00:35:11,940 --> 00:35:12,940 for Americans. 421 00:35:12,940 --> 00:35:17,940 And in SNAP, we just finished the Thrifty Food Plan Re-evaluation. 422 00:35:17,940 --> 00:35:22,740 The Thrifty Food Plan is what forms the basis of SNAP allotments. 423 00:35:22,740 --> 00:35:28,230 And I’ll talk about that in just a minute. 424 00:35:28,230 --> 00:35:32,790 The Thrifty Food Plan Re-evaluation was important because in the 2018 Farm Bill, Congress required 425 00:35:32,790 --> 00:35:38,690 us to look at that and put it on a 5-year interval so that we’ll be doing re-evaluations 426 00:35:38,690 --> 00:35:40,710 of the Thrifty every 5 years. 427 00:35:40,710 --> 00:35:45,119 Prior to that, it was at the Secretary’s discretion. 428 00:35:45,119 --> 00:35:50,930 And it had only been done a couple of times in the 40-year lifespan of the Thrifty Food Plan. 429 00:35:50,930 --> 00:35:55,790 And the last time was about 15 years ago in 2006. 430 00:35:55,790 --> 00:35:59,310 In fact, President Biden was so committed to this that in his very first week in office, 431 00:35:59,310 --> 00:36:04,230 he had an executive order encouraging USDA to prioritize this review. 432 00:36:04,230 --> 00:36:10,480 So, we did that, we looked at that, it’s based on a mathematical optimization model 433 00:36:10,480 --> 00:36:16,320 that looks at what people eat, what the dietary guidelines say people should be eating, what 434 00:36:16,320 --> 00:36:22,880 food compositions and the vitamins and minerals in our foods, how they support healthy eating. 435 00:36:22,880 --> 00:36:28,450 And then what the cost of groceries is today, puts those into a mathematical optimization 436 00:36:28,450 --> 00:36:32,869 model, which I’m happy to describe in more detail for those of you who are interested 437 00:36:32,869 --> 00:36:39,250 and looks at what is the cost of the nutritious practical cost-effective diet, 438 00:36:39,250 --> 00:36:46,839 And the results of that re-evaluation indicated that the maximum allotments for SNAP would 439 00:36:46,839 --> 00:36:49,510 need to increase by about 21 percent. 440 00:36:49,510 --> 00:36:56,589 What that means, practically, when that translates into SNAP benefits, is about $43 increase 441 00:36:56,589 --> 00:37:03,650 per month for a one-person household or an $80 increase per month for a two-person household, 442 00:37:03,650 --> 00:37:07,590 which constitute about 70 percent of SNAP households. 443 00:37:07,590 --> 00:37:16,070 So, to break that down even further by person, what that means is about $1.19 per person 444 00:37:16,070 --> 00:37:22,440 per day increase, or about 40 cents per meal per person increase, when these go into effect 445 00:37:22,440 --> 00:37:23,440 on October 1. 446 00:37:23,440 --> 00:37:32,961 And the big additional efforts that the department is focusing on in order to promote nutrition 447 00:37:32,961 --> 00:37:38,211 security, which again is access to nutritious foods, is really looking at its nutrition 448 00:37:38,211 --> 00:37:45,160 promotion and nutrition education efforts to ensure that folks have access to the foods 449 00:37:45,160 --> 00:37:49,670 but then also that they know how to purchase and prepare foods that can support a healthy 450 00:37:49,670 --> 00:37:51,569 and active life. 451 00:37:51,569 --> 00:37:56,780 So, one of the things that we’re working on is enhancing SNAP and SNAP education. 452 00:37:56,780 --> 00:38:03,119 Many people don’t necessarily know that a big part of the SNAP budget is the SNAP 453 00:38:03,119 --> 00:38:09,599 nutrition education and obesity prevention grants, which each state gets each year to 454 00:38:09,599 --> 00:38:15,120 create community-based and public health approaches, to facilitate greater access to nutrition 455 00:38:15,120 --> 00:38:22,780 education, enhanced collaboration and coordination among program partners and implementing agencies 456 00:38:22,780 --> 00:38:26,110 and improve dietary behaviors among eligible audiences. 457 00:38:26,110 --> 00:38:32,359 We’re working to guide implementation of expanded SNAP benefits through the Thrifty 458 00:38:32,359 --> 00:38:38,650 to encourage adequate diets, positive nutrition behaviors among SNAP program partners, SNAP 459 00:38:38,650 --> 00:38:45,180 retailers, farmer’s markets, consumer venues, and SNAP-Ed implementing agencies and program 460 00:38:45,180 --> 00:38:46,180 participants. 461 00:38:46,180 --> 00:38:52,599 We also want to increase federal-level cross-program collaboration partnerships and guidance 462 00:38:52,599 --> 00:38:57,320 for cross-program Food and Nutrition security support to our state partners. 463 00:38:57,320 --> 00:39:04,670 SNAP and SNAP-Ed will be working with other FNS programs such as the Child Nutrition programs, 464 00:39:04,670 --> 00:39:11,070 and the Center for Nutrition and Policy Promotion to engage in the development of communications, 465 00:39:11,070 --> 00:39:18,750 promotion interventions and educational strategies to increase awareness and access to resources 466 00:39:18,750 --> 00:39:21,470 around the Thrifty and its implementation. 467 00:39:21,470 --> 00:39:27,240 And SNAP will be emphasizing, engaging underserved communities, diverse stakeholders and service 468 00:39:27,240 --> 00:39:29,330 providers throughout this process. 469 00:39:29,330 --> 00:39:37,480 As I mentioned also, the WIC 390 program is looking at innovative strategies to ensure 470 00:39:37,480 --> 00:39:41,490 that folks have access to our programs, and will be redeeming the benefits to which they’re 471 00:39:41,490 --> 00:39:46,238 eligible so that they’re getting access to that important food prescription, which 472 00:39:46,238 --> 00:39:50,859 is based on specific nutrition needs. 473 00:39:50,859 --> 00:39:55,348 Thank you very much for the opportunity to speak today. 474 00:39:55,348 --> 00:40:01,178 I am happy to answer questions when the time comes up. 475 00:40:01,178 --> 00:40:06,740 DR. ALISHA COLEMAN-JENSEN: Hello, my name is Alisha Coleman-Jensen from USDA's Economic Research 476 00:40:06,740 --> 00:40:07,740 Service. 477 00:40:07,740 --> 00:40:10,640 I’m pleased to speak with you today about food security. 478 00:40:10,640 --> 00:40:15,839 I’ll be presenting an overview of food security measurement, and talking about food security 479 00:40:15,839 --> 00:40:20,839 data sources, and also presenting findings from our most recent annual food security 480 00:40:20,839 --> 00:40:27,359 report, Household Food Security in the United States in 2020. 481 00:40:27,359 --> 00:40:31,250 To make sure we’re all on a same page, let’s start by talking about the food security 482 00:40:31,250 --> 00:40:32,250 definitions. 483 00:40:32,250 --> 00:40:38,319 So, food security means access at all times to enough food for an active healthy life 484 00:40:38,319 --> 00:40:41,120 for all household members. 485 00:40:41,120 --> 00:40:46,790 Food insecurity means being unable, at some time during the year, to provide adequate 486 00:40:46,790 --> 00:40:51,400 food for one or more household members because of a lack of resources. 487 00:40:51,400 --> 00:40:54,369 I’d like to unpack this definition a little bit. 488 00:40:54,369 --> 00:41:00,420 So, being able...unable at some time during the year, a household may experience food 489 00:41:00,420 --> 00:41:05,810 insecurity for a single occurrence. For example, if they experienced unemployment, whereas 490 00:41:05,810 --> 00:41:08,720 some other households may be more chronically food insecure. 491 00:41:08,720 --> 00:41:14,119 But a single occurrence of food insecurity would classify a household as food insecure 492 00:41:14,119 --> 00:41:16,360 for the year. 493 00:41:16,360 --> 00:41:21,250 Being unable to provide adequate food for one or more household members. 494 00:41:21,250 --> 00:41:23,940 Food insecurity is measured at the household level. 495 00:41:23,940 --> 00:41:29,440 And if a single household member’s food insecure, the entire household is food insecure. 496 00:41:29,440 --> 00:41:34,150 This is particularly relevant when we think about food insecurity among children. 497 00:41:34,150 --> 00:41:39,839 Because in some instances, parents will report food insecurity among adults, but children 498 00:41:39,839 --> 00:41:42,770 may be less affected by reduced food intake. 499 00:41:42,770 --> 00:41:48,460 But if a single household member is food insecure, the entire household would be classified as 500 00:41:48,460 --> 00:41:50,300 food insecure. 501 00:41:50,300 --> 00:41:52,470 And finally, because of a lack of resources. 502 00:41:52,470 --> 00:41:58,100 So, this is about not having enough money or other resources to acquire food. 503 00:41:58,100 --> 00:42:01,980 This is not about dieting, or not having enough time to eat. 504 00:42:01,980 --> 00:42:09,020 Very low food security is the more severe range of food insecurity. 505 00:42:09,020 --> 00:42:13,849 Very low food security means that normal eating patterns of some household members were disrupted 506 00:42:13,849 --> 00:42:18,520 at times during the year and their food intake reduced because they could not afford enough 507 00:42:18,520 --> 00:42:19,520 food. 508 00:42:19,520 --> 00:42:25,410 What we...what we mean by normal eating patterns being disrupted, is that households are telling 509 00:42:25,410 --> 00:42:31,569 us that they’re skipping meals, or in more severe situations, going an entire day without 510 00:42:31,569 --> 00:42:32,569 eating. 511 00:42:32,569 --> 00:42:35,970 And they’re telling us that they’re just not able to get enough to eat because they 512 00:42:35,970 --> 00:42:40,260 can’t afford enough food. 513 00:42:40,260 --> 00:42:42,559 How is food security measured? 514 00:42:42,559 --> 00:42:48,800 Food insecurity is a continuum like many things, and early research showed that food insecurity 515 00:42:48,800 --> 00:42:54,570 was a managed process, meaning households had some control over how food insecurity 516 00:42:54,570 --> 00:42:56,640 is experienced. 517 00:42:56,640 --> 00:43:01,030 So, we hope that all households can afford enough healthy food. 518 00:43:01,030 --> 00:43:07,690 But as households may begin to struggle with food insecurity, as their food security deteriorates, 519 00:43:07,690 --> 00:43:14,440 households may become anxious about the household food supply and try to stretch their food 520 00:43:14,440 --> 00:43:15,440 and food budget. 521 00:43:15,440 --> 00:43:20,260 They may try to juggle household spending to try to maintain food security. 522 00:43:20,260 --> 00:43:26,440 As food insecurity worsens, households may reduce the quality and variety of food or 523 00:43:26,440 --> 00:43:28,579 rely on low cost foods. 524 00:43:28,579 --> 00:43:32,150 And this is defined as having low food security. 525 00:43:32,150 --> 00:43:37,520 And as food insecurity becomes still more severe, adults may reduce their own food intake 526 00:43:37,520 --> 00:43:41,130 while trying to ensure children get enough to eat. 527 00:43:41,130 --> 00:43:44,330 And in the most severe situations, we see reductions in food intake among children. 528 00:43:44,330 --> 00:43:54,320 And this reduced food intake is classified as very low food security. 529 00:43:54,320 --> 00:43:58,710 Households are asked a series of 10 questions about food insecurity for the household as 530 00:43:58,710 --> 00:44:01,180 a whole, and adults in the household. 531 00:44:01,180 --> 00:44:07,579 Households with children are asked an additional eight items about children’s food insecurity. 532 00:44:07,579 --> 00:44:12,410 These questions follow the full range of severity of food insecurity that we discussed on the 533 00:44:12,410 --> 00:44:14,790 last slide. 534 00:44:14,790 --> 00:44:19,930 Households must respond affirmatively to at least three items indicating food insecurity 535 00:44:19,930 --> 00:44:22,710 to be considered food insecure. 536 00:44:22,710 --> 00:44:26,790 And here I show some examples of food security survey items. 537 00:44:26,790 --> 00:44:31,730 And the full set of items can be found on the Economic Research Service website, and 538 00:44:31,730 --> 00:44:35,819 also in our annual report that was released last week. 539 00:44:35,819 --> 00:44:39,981 We worried whether our food would run out before we got money to buy more, was that 540 00:44:39,981 --> 00:44:45,109 often, sometimes or never true for you in the last 12 months? 541 00:44:45,109 --> 00:44:47,420 We couldn’t afford to eat balanced meals? 542 00:44:47,420 --> 00:44:53,040 Was that often, sometimes, or never true for you in the last 12 months? 543 00:44:53,040 --> 00:44:54,040 A more severe item. 544 00:44:54,040 --> 00:44:58,599 In the last 12 months, did you ever cut the size of your meals or skip meals because there 545 00:44:58,599 --> 00:45:00,230 wasn’t enough money for food? 546 00:45:00,230 --> 00:45:02,150 And the most severe item: 547 00:45:02,150 --> 00:45:07,360 In the last 12 months, did you ever not eat for a whole day because there wasn’t enough 548 00:45:07,360 --> 00:45:08,940 money for food? 549 00:45:08,940 --> 00:45:15,260 And you’ll notice that these questions follow along with the definition, in terms of stipulating 550 00:45:15,260 --> 00:45:20,970 that this is about not having enough money for food, and also asking about the last 12 551 00:45:20,970 --> 00:45:28,220 months, if these experiences sometimes or ever happened in the last 12 months. 552 00:45:28,220 --> 00:45:34,810 There are a number of surveys that include food security measures. 553 00:45:34,810 --> 00:45:39,550 First, I’ll talk about the Current Population Survey Food Security Supplement. 554 00:45:39,550 --> 00:45:45,079 The Current Population Survey is also the source for federal poverty and unemployment 555 00:45:45,079 --> 00:45:46,079 statistics. 556 00:45:46,079 --> 00:45:51,730 The U.S. Census Bureau conducts the Food Security Survey for USDA's Economic Research Service 557 00:45:51,730 --> 00:45:59,150 and December each year, as a supplement to Census's monthly Current Population Survey. 558 00:45:59,150 --> 00:46:05,559 The 2020 food security survey interviewed about 34,330 households and was a representative 559 00:46:05,559 --> 00:46:09,200 sample of the U.S. civilian population. 560 00:46:09,200 --> 00:46:13,930 And the Current Population Survey Food Security Supplement also includes information on use 561 00:46:13,930 --> 00:46:20,190 of food programs, food spending, and because it’s part of the CPS income on an...information 562 00:46:20,190 --> 00:46:21,640 on income and employment. 563 00:46:21,640 --> 00:46:27,819 There are a number of surveys that can be used to understand the relationships between 564 00:46:27,819 --> 00:46:30,400 health and food insecurity. 565 00:46:30,400 --> 00:46:32,420 And some of those are shown here. 566 00:46:32,420 --> 00:46:38,309 The National Health and Nutrition Examination Survey includes food security, and also detailed 567 00:46:38,309 --> 00:46:43,750 information on food intake and nutritional status along with health measures. 568 00:46:43,750 --> 00:46:48,740 The National Health Interview Survey includes the food security measure and also detailed 569 00:46:48,740 --> 00:46:54,750 information on health status, chronic conditions, health care access and use and can also be 570 00:46:54,750 --> 00:47:00,800 linked to the Medical Expenditure Panel Survey to assess linkages between food insecurity 571 00:47:00,800 --> 00:47:02,119 and medical expenditures. 572 00:47:02,119 --> 00:47:09,650 The National Survey of Children’s Health, includes a single item about food insufficiency, 573 00:47:09,650 --> 00:47:15,900 so this is a little bit different from the food insecurity measure but is similar in 574 00:47:15,900 --> 00:47:16,990 concept. 575 00:47:16,990 --> 00:47:23,190 Then NSCH also includes measures of children’s health status and access to health care and 576 00:47:23,190 --> 00:47:29,010 information on the family, neighborhood, school, and social contexts. 577 00:47:29,010 --> 00:47:33,950 These data sources can be used to understand the multiple pathways through which food 578 00:47:33,950 --> 00:47:39,480 insecurity can affect health, such as diet and nutrition, adherence to medical treatment, 579 00:47:39,480 --> 00:47:44,609 health care utilization, and other factors. 580 00:47:44,609 --> 00:47:49,900 I’d like to turn now and talk about the findings from our most recent annual food 581 00:47:49,900 --> 00:47:52,750 security report. 582 00:47:52,750 --> 00:47:57,839 In 2020, 89.5 percent of U.S. households were food secure throughout the year. 583 00:47:57,839 --> 00:48:02,849 Food secure, again, means that they had consistent access to adequate food for active healthy 584 00:48:02,849 --> 00:48:06,710 living for all household members throughout the year. 585 00:48:06,710 --> 00:48:08,950 10.5 percent of households were food insecure. 586 00:48:08,950 --> 00:48:12,970 That’s about 13.8 million households. 587 00:48:12,970 --> 00:48:17,520 Food insecure households were unable, at some time during the year, to provide adequate 588 00:48:17,520 --> 00:48:23,410 quantity or quality of food for one or more household members due to a lack of resources 589 00:48:23,410 --> 00:48:30,030 We separate food insecure households into either having low food security or 590 00:48:30,030 --> 00:48:34,500 very low food security. 591 00:48:34,500 --> 00:48:39,990 Households reporting food acquisition problems, but few, if any indications of reduced food 592 00:48:39,990 --> 00:48:43,650 intake, are classified as low food secure. 593 00:48:43,650 --> 00:48:50,329 For these households, inadequate food meant primarily inadequate in quality, variety, or 594 00:48:50,329 --> 00:48:54,280 desirability, not in quantity of food. 595 00:48:54,280 --> 00:49:03,690 6.6 percent of U.S. households were categorized as having low food security in 2020. 596 00:49:03,690 --> 00:49:08,180 3.9 percent of U.S. households were very low food secure in 2020. 597 00:49:08,180 --> 00:49:15,599 This subset of food insecure households was in the more severe range of food insecurity, 598 00:49:15,599 --> 00:49:19,309 and that’s about 5.1 million households. 599 00:49:19,309 --> 00:49:24,160 Households classified as having had very low food security reported that normal eating 600 00:49:24,160 --> 00:49:29,070 patterns of some household members were disrupted at times during the year and their food intake 601 00:49:29,070 --> 00:49:32,380 reduced below levels they considered appropriate. 602 00:49:32,380 --> 00:49:37,099 Most households with very low food security reported that an adult in the household had 603 00:49:37,099 --> 00:49:42,619 been hungry at times, but did not eat because there wasn’t enough money for food. 604 00:49:42,619 --> 00:49:48,980 I’d like to turn now to trends in food insecurity to provide some historical context. 605 00:49:48,980 --> 00:49:56,770 In 2008, food insecurity increased substantially to 14.6 percent and peaked at 14.9 percent 606 00:49:56,770 --> 00:49:58,220 in 2011. 607 00:49:58,220 --> 00:50:06,270 We saw several subsequent declines in food insecurity since that time, and in 2019, 10.5 608 00:50:06,270 --> 00:50:11,200 percent of U.S. households were food insecure, and the percentage of U.S. households that were 609 00:50:11,200 --> 00:50:16,559 food insecure in 2020 was unchanged from 2019. 610 00:50:16,559 --> 00:50:21,609 The COVID-19 pandemic began in the United States in 2020 and affected public health 611 00:50:21,609 --> 00:50:26,440 and the economy, and there was a substantial increase in assistance, including nutrition 612 00:50:26,440 --> 00:50:29,130 assistance and other benefits. 613 00:50:29,130 --> 00:50:32,920 These many changes may have affected food insecurity in different ways, and our recent 614 00:50:32,920 --> 00:50:40,010 annual Food Security Report does not provide an analysis of possible causal impacts, but 615 00:50:40,010 --> 00:50:45,130 we do know from previous research that increases in nutrition assistance and other benefits 616 00:50:45,130 --> 00:50:47,609 help to reduce food insecurity. 617 00:50:47,609 --> 00:50:53,990 The red line near the bottom of the graph shows the prevalence of very low food security. 618 00:50:53,990 --> 00:51:02,430 In 2008, 5.7 percent of U.S. households experienced very low food security, and we saw declines 619 00:51:02,430 --> 00:51:05,500 to 4.1 percent in 2019. 620 00:51:05,500 --> 00:51:12,290 In 2020, 3.9 percent of U.S. households were food insecure and that difference from 2019 621 00:51:12,290 --> 00:51:15,500 to 2020 was not statistically significant. 622 00:51:15,500 --> 00:51:22,840 This chart includes a lot of information, if you’re interested in looking at the underlying 623 00:51:22,840 --> 00:51:27,810 statistics in more detail, you can find those in Table Two of Household Food Security in 624 00:51:27,810 --> 00:51:29,640 the United States in 2020. 625 00:51:29,640 --> 00:51:32,650 They’re also available on our website. 626 00:51:32,650 --> 00:51:37,040 So there are two important takeaways from this chart, first, it shows those household 627 00:51:37,040 --> 00:51:40,369 characteristics related to a higher prevalence of food insecurity. 628 00:51:40,369 --> 00:51:45,410 The patterns of groups with a relatively higher prevalence of food insecurity tend to be the 629 00:51:45,410 --> 00:51:46,839 same from year to year. 630 00:51:46,839 --> 00:51:51,630 In 2020, food insecurity rates were highest for all households with children, especially 631 00:51:51,630 --> 00:51:56,319 for single mother families and single father families. 632 00:51:56,319 --> 00:52:02,740 Food insecurity rates were higher for households with reference persons who are Black, non-Hispanic, 633 00:52:02,740 --> 00:52:03,770 or Hispanic. 634 00:52:03,770 --> 00:52:10,309 A reference person is an adult household member in the survey who owns or rents the housing 635 00:52:10,309 --> 00:52:11,309 units sampled. 636 00:52:11,309 --> 00:52:15,880 Food insecurity is also higher for low income households, which is to be expected given 637 00:52:15,880 --> 00:52:20,609 that food insecurity is related to constrained resources. 638 00:52:20,609 --> 00:52:27,270 Food insecurity was higher in principal cities within metropolitan areas and in non-metropolitan 639 00:52:27,270 --> 00:52:28,320 areas. 640 00:52:28,320 --> 00:52:32,790 The second takeaway from this graph is that it shows changes in the prevalence of food 641 00:52:32,790 --> 00:52:37,100 insecurity by household characteristics between 2019 and 2020. 642 00:52:37,100 --> 00:52:44,800 Bars marked with an asterisk show a statistically significant change in the prevalence rate 643 00:52:44,800 --> 00:52:45,990 between years. 644 00:52:45,990 --> 00:52:51,010 Statistical significance is related both to the size of the change and the margins of 645 00:52:51,010 --> 00:52:52,309 error around the estimates. 646 00:52:52,309 --> 00:52:58,571 Food insecurity increased significantly for all households with children from 2019 to 647 00:52:58,571 --> 00:53:05,370 2020, for married couples with children and for households with Black non-Hispanic reference 648 00:53:05,370 --> 00:53:07,339 persons. 649 00:53:07,339 --> 00:53:15,950 Food insecurity declined significantly for men and women living alone in households with 650 00:53:15,950 --> 00:53:19,109 white non-Hispanic reference persons. 651 00:53:19,109 --> 00:53:24,049 We’ll also be talking during the conference about the use of federal nutrition assistance 652 00:53:24,049 --> 00:53:25,049 programs. 653 00:53:25,049 --> 00:53:31,190 In 2020, about 55 percent of food insecure households participated in one of the three 654 00:53:31,190 --> 00:53:36,590 largest nutrition assistance programs. About 42 percent use SNAP. 655 00:53:36,590 --> 00:53:41,520 Note that these are based on self-reported survey data, so there is some underreporting 656 00:53:41,520 --> 00:53:42,760 of program participation. 657 00:53:42,760 --> 00:53:49,630 Participation in the free or reduced price school lunch program was lower than in 2019, 658 00:53:49,630 --> 00:53:53,490 likely due to school closures and possibly because parents did not report receive grab 659 00:53:53,490 --> 00:53:55,390 and go school meals. 660 00:53:55,390 --> 00:54:05,710 About 6.7 percent of U.S. households used food pantries in 2020, and that is an increase 661 00:54:05,710 --> 00:54:06,710 from 2019. 662 00:54:06,710 --> 00:54:12,240 Use of food pantries was more common among those that were food insecure. Thirty-seven percent 663 00:54:12,240 --> 00:54:18,920 of food insecure households used food pantries and 46 percent of very low food secure households 664 00:54:18,920 --> 00:54:21,150 used food pantries. 665 00:54:21,150 --> 00:54:26,630 Use of soup kitchens was much less common overall, but similarly more common among those 666 00:54:26,630 --> 00:54:29,290 that were food insecure. 667 00:54:29,290 --> 00:54:35,980 I’ll close this presentation by reminding that food insecurity was unchanged from 10.5 668 00:54:35,980 --> 00:54:40,430 percent in 2019 to 10.5 percent in 2020. 669 00:54:40,430 --> 00:54:45,911 There were some increases in food insecurity for some groups, including households with 670 00:54:45,911 --> 00:54:46,911 children. 671 00:54:46,911 --> 00:54:52,250 The prevalence of food insecurity increased for all households with children from 13.6 672 00:54:52,250 --> 00:54:56,730 percent in 2019 to 14.8 percent in 2020. 673 00:54:56,730 --> 00:55:06,080 I also want to refer you to our website for a lot of information on survey tools and modules 674 00:55:06,080 --> 00:55:12,000 to measure food insecurity in U.S. households, along with information on data, graphics, and 675 00:55:12,000 --> 00:55:16,460 interactive charts that you can download and a number of research reports and articles 676 00:55:16,460 --> 00:55:18,380 that may be of interest. 677 00:55:18,380 --> 00:55:19,380 Thank you. 678 00:55:19,380 --> 00:55:27,280 DR. SHERI WEISER: Hello, I’m Sheri Weiser, a professor of medicine in the Division of 679 00:55:27,280 --> 00:55:32,559 HIV, Infectious Diseases, and Global Medicine at UCSF, and I’m also founding co-director 680 00:55:32,559 --> 00:55:36,520 for the University of California-wide Center on Climate, Health, and Equity. 681 00:55:36,520 --> 00:55:40,980 Today, I’m going to be reviewing the pathways through which food insecurity increases the 682 00:55:40,980 --> 00:55:45,599 risk of obesity and cardiometabolic diseases. 683 00:55:45,599 --> 00:55:51,970 So in 2020, 38 million people in the U.S. lived in food insecure households. 684 00:55:51,970 --> 00:55:58,400 We know that food insecurity is an important driver of chronic health disparities and disproportionately 685 00:55:58,400 --> 00:56:02,690 impacts low income and minoritized groups. 686 00:56:02,690 --> 00:56:09,200 Food insecurity negatively impacts cardiometabolic health along the entire cascade of care, from 687 00:56:09,200 --> 00:56:14,390 disease acquisition to linkage and retention in care to higher morbidity and mortality. 688 00:56:14,390 --> 00:56:21,310 There’s in fact, a large body of literature linking food insecurity to obesity, and also, 689 00:56:21,310 --> 00:56:23,869 studies show that sociodemographic characteristics can modify associations. 690 00:56:23,869 --> 00:56:30,720 So, for example, in a study by Penn et. al., using behavioral risk factor surveillance 691 00:56:30,720 --> 00:56:37,800 system data from over 66,000 adults in 12 U.S. states, people who were food insecure had 692 00:56:37,800 --> 00:56:44,230 32 percent higher odds of being obese in adjusted analyses and being female and having gone 693 00:56:44,230 --> 00:56:51,079 to college as you can see, increased these odds further among food insecure adults. 694 00:56:51,079 --> 00:56:57,829 As another example, a 2017 study from Hernandez et al., used National Health Interview Survey 695 00:56:57,829 --> 00:57:03,549 data to look at the association between food insecurity and obesity and also to determine 696 00:57:03,549 --> 00:57:07,480 whether this association differed by race and ethnicity. 697 00:57:07,480 --> 00:57:12,500 So while black and Hispanic women were more likely to be food insecure and obese compared 698 00:57:12,500 --> 00:57:18,130 to white women, food insecurity, in fact, predicted obesity more strongly among white women. 699 00:57:18,130 --> 00:57:23,069 So specifically, white adults who were food insecure had 41 percent higher odds of being 700 00:57:23,069 --> 00:57:29,110 obese or overweight, compared to 29 percent higher odds for food insecure Hispanic women. 701 00:57:29,110 --> 00:57:34,079 And there was no association between food insecurity and overweight and obesity status 702 00:57:34,079 --> 00:57:37,039 among Black women. 703 00:57:37,039 --> 00:57:41,210 In addition to obesity, we know that food insecurity has been linked with a number of 704 00:57:41,210 --> 00:57:43,370 cardiometabolic and chronic diseases. 705 00:57:43,370 --> 00:57:48,530 And just for a few examples, food insecurity has been associated with 27 percent higher 706 00:57:48,530 --> 00:57:54,300 odds of having diabetes, 42 percent higher odds of hypertension, 38 percent higher odds 707 00:57:54,300 --> 00:58:00,549 of nonalcoholic fatty liver disease, 46 percent higher odds of chronic kidney disease and 708 00:58:00,549 --> 00:58:05,829 53 percent higher odds of cardiovascular disease mortality. 709 00:58:05,829 --> 00:58:10,630 So food insecurity and cardiometabolic health are really intertwined in a vicious cycle, 710 00:58:10,630 --> 00:58:16,140 with each enhancing vulnerability to and worsening the severity of the other condition. 711 00:58:16,140 --> 00:58:20,630 On the left, you can see that there are several structural drivers of food insecurity at the 712 00:58:20,630 --> 00:58:26,140 community level including socioeconomic factors like poverty and lack of access to education 713 00:58:26,140 --> 00:58:29,870 and social factors, like gender inequality and racism. 714 00:58:29,870 --> 00:58:34,290 Food insecurity typically operates at the level of the household and is also influenced 715 00:58:34,290 --> 00:58:39,309 by other household level factors like family structure and social support. 716 00:58:39,309 --> 00:58:45,329 Food insecurity, in turn, shapes cardiometabolic health outcomes through mental health, immune 717 00:58:45,329 --> 00:58:48,309 activation and behavioral pathways. 718 00:58:48,309 --> 00:58:53,559 These then contribute to conditions like obesity, diabetes, hypertension and cardiovascular 719 00:58:53,559 --> 00:58:57,970 disease, and also worse outcomes among those affected. 720 00:58:57,970 --> 00:59:02,130 Morbidity from these conditions then can lead to more acute care utilization, greater out-of-pocket 721 00:59:02,130 --> 00:59:06,990 health expenses, and also to poor health-related quality of life and then this creates a vicious 722 00:59:06,990 --> 00:59:07,990 cycle. 723 00:59:07,990 --> 00:59:13,059 As people get sicker, they have worse functioning, incur greater medical costs and may face unemployment, 724 00:59:13,059 --> 00:59:16,780 all of which then go back to exacerbate food insecurity. 725 00:59:16,780 --> 00:59:20,510 And I’m going to be using this framework as a way to walk through data on these mechanistic 726 00:59:20,510 --> 00:59:22,820 pathways. 727 00:59:22,820 --> 00:59:25,369 So let’s start with the mental health pathway. 728 00:59:25,369 --> 00:59:31,230 Food insecurity leads to stress, depression, anxiety, and increased drug and alcohol use 729 00:59:31,230 --> 00:59:36,589 disorders, and this poor overall mental health status then has important impacts on our physical 730 00:59:36,589 --> 00:59:37,589 health. 731 00:59:37,589 --> 00:59:43,200 So in a systematic review and meta-analysis comprising over 300,000 individuals across 732 00:59:43,200 --> 00:59:48,859 10 countries, food insecurity was found to increase the odds of depression by 40 percent. 733 00:59:48,859 --> 00:59:54,180 The association was in fact universal across the 10 countries, and 19 studies looked at 734 00:59:54,180 --> 00:59:59,060 and was greater among the elderly and also intensified with worsening severity of food 735 00:59:59,060 --> 01:00:00,250 insecurity. 736 01:00:00,250 --> 01:00:05,410 The odds of stress was similarly higher, so 34 percent greater in food insecure groups, 737 01:00:05,410 --> 01:00:08,940 and this was observed in all countries included in the study. 738 01:00:08,940 --> 01:00:14,530 Finally, food insecurity was associated with 29 percent greater odds of anxiety in North 739 01:00:14,530 --> 01:00:16,339 American settings. 740 01:00:16,339 --> 01:00:23,260 So, our team found similar results in the Women’s Interagency HIV study, which is a prospective 741 01:00:23,260 --> 01:00:28,839 cohort study of women at risk of or living with HIV from multiple sites in the United 742 01:00:28,839 --> 01:00:30,260 States. 743 01:00:30,260 --> 01:00:35,710 So we used longitudinal data over a three year period and found that current and past 744 01:00:35,710 --> 01:00:41,700 food insecurity were associated with higher depression scores measured on the CESD depression 745 01:00:41,700 --> 01:00:47,099 scale and lower mental health summary scores on the MOS HIV Mental Health Summary Score. 746 01:00:47,099 --> 01:00:51,900 And this was even after adjusting for sociodemographic and clinical factors. 747 01:00:51,900 --> 01:00:55,990 And Whittle et. al., in our group also found that food insecurity was associated with higher 748 01:00:55,990 --> 01:01:01,930 generalized anxiety disorder scores, post-traumatic stress disorder scores and perceived stress 749 01:01:01,930 --> 01:01:05,950 scores in a dose-dependent manner. 750 01:01:05,950 --> 01:01:10,470 Food insecurity can, in fact, alter metabolic processes through this stress pathway. 751 01:01:10,470 --> 01:01:16,299 So specifically, food scarcity may trigger stress, which then activates the hypothalamic 752 01:01:16,299 --> 01:01:23,080 pituitary adrenal axis or the HPA axis, and also stimulates glucocorticoid release, which 753 01:01:23,080 --> 01:01:27,730 then can increase both visceral fat storage and accumulation. 754 01:01:27,730 --> 01:01:33,220 Food scarcity-related stress can also activate the reward pathway and memory, and this can 755 01:01:33,220 --> 01:01:38,930 explain why people that are stressed may be drawn to high fat, high sugar comfort foods. 756 01:01:38,930 --> 01:01:44,440 High cortisol in response to stress has also been associated with increased caloric intake 757 01:01:44,440 --> 01:01:47,690 and binge eating, particularly in women. 758 01:01:47,690 --> 01:01:52,059 So we know that increased cortisol levels in turn can increase blood glucose and insulin 759 01:01:52,059 --> 01:01:57,130 levels, which play a critical role in the pathogenesis of diabetes, and then stress 760 01:01:57,130 --> 01:02:02,390 related alterations that are sympathetic and autonomic nervous system activity in the HPA 761 01:02:02,390 --> 01:02:08,710 axis and also in inflammatory cytokines are associated with endothelial dysfunction, 762 01:02:08,710 --> 01:02:12,520 increases in blood pressure and heart rate, and decreases in vascular reactivity. 763 01:02:12,520 --> 01:02:19,250 In addition to stress, mental health problems related to food insecurity could also increase 764 01:02:19,250 --> 01:02:22,359 the risk for cardiovascular and metabolic problems. 765 01:02:22,359 --> 01:02:27,819 So a large scale meta analysis by Correll et. al., looked at the prevalence and incidence 766 01:02:27,819 --> 01:02:32,720 of cardiovascular disease among patients with severe mental illness, and they found that 767 01:02:32,720 --> 01:02:36,960 depression was associated with 75 percent greater odds of cardiovascular disease and 768 01:02:36,960 --> 01:02:42,319 150 percent greater odds of coronary artery disease. 769 01:02:42,319 --> 01:02:47,740 Another study from Singapore by Zhu et. al., which is shown in the figure on the left, 770 01:02:47,740 --> 01:02:53,050 followed young adults with both type 1 and type 2 diabetes for 2 years, and they 771 01:02:53,050 --> 01:02:56,900 found that those with anxiety at baseline consistently had higher levels of hemoglobin 772 01:02:56,900 --> 01:03:02,859 A1c, than those without anxiety throughout the entire study period. 773 01:03:02,859 --> 01:03:08,450 Moving on to the second pathway, food insecurity is associated with immune activation and inflammation, 774 01:03:08,450 --> 01:03:10,690 which negatively affects health. 775 01:03:10,690 --> 01:03:16,170 Poor diet quality also affects our microbiome, which impairs immune functioning, contributing 776 01:03:16,170 --> 01:03:19,029 to worse cardiometabolic health. 777 01:03:19,029 --> 01:03:24,150 So in this framework, from Kau et. al., published in Nature, we see that food insecurity and 778 01:03:24,150 --> 01:03:29,170 subsequent undernutrition can really change the gut microbiota, which can impair both 779 01:03:29,170 --> 01:03:34,090 gut and immune functioning and thereby make individuals more susceptible to infectious 780 01:03:34,090 --> 01:03:35,090 diseases. 781 01:03:35,090 --> 01:03:40,700 A suboptimal microbiome can also impair nutrient absorption, which then contributes to micronutrient 782 01:03:40,700 --> 01:03:42,310 deficiencies. 783 01:03:42,310 --> 01:03:47,450 So in addition to undernutrition, studies show that diet-induced perturbations of the 784 01:03:47,450 --> 01:03:53,609 gut microbiome can precipitate obesity, insulin resistance, type 2 diabetes and other cardiometabolic 785 01:03:53,609 --> 01:03:58,970 conditions, and this could occur through a variety of potential mechanisms, but including 786 01:03:58,970 --> 01:04:01,470 immune activation through bacterial translocation. 787 01:04:01,470 --> 01:04:07,720 Low fiber, high fat and high sugar diets, which we know are typical among individuals 788 01:04:07,720 --> 01:04:12,880 with food insecurity, have also been shown to negatively impact the composition of the 789 01:04:12,880 --> 01:04:13,890 gut microbiome. 790 01:04:13,890 --> 01:04:19,460 And conversely, diets high in fruit and vegetables and low in meat are associated with a highly 791 01:04:19,460 --> 01:04:22,510 diverse microbiota. 792 01:04:22,510 --> 01:04:28,480 So turning to some data, a cross-sectional NHANES study with 12,000 participants by 793 01:04:28,480 --> 01:04:33,470 Gowda et. al., looked at potential pathways through which food insecurity may be associated 794 01:04:33,470 --> 01:04:35,910 with inflammation and adverse health outcomes. 795 01:04:35,910 --> 01:04:41,260 So they found that highly food insecure individuals had 36 percent higher odds of having a high 796 01:04:41,260 --> 01:04:47,609 white blood cell count and 21 percent higher odds of having higher CRP levels, and in mediation 797 01:04:47,609 --> 01:04:52,299 models, white blood cell count was at least a partial mediator of the relationship between 798 01:04:52,299 --> 01:04:55,950 food insecurity and C-reactive protein levels. 799 01:04:55,950 --> 01:05:00,350 In our data from the wise cohort among women living with HIV in the United States, Leddy 800 01:05:00,350 --> 01:05:05,520 et. al., found that food insecurity was associated with higher levels of inflammatory markers 801 01:05:05,520 --> 01:05:10,510 such as TNFR1 and interleukin-6, in adjusted analyses. 802 01:05:10,510 --> 01:05:16,670 And importantly, we saw significant effects, even among those who were both virally suppressed 803 01:05:16,670 --> 01:05:21,680 and had high CD4 cell counts. So, CD4 cell counts greater than 500, which really suggests 804 01:05:21,680 --> 01:05:25,529 that poor HIV control did not explain our associations. 805 01:05:25,529 --> 01:05:29,930 We then hypothesized that this inflammation may be on the causal pathway between food 806 01:05:29,930 --> 01:05:33,619 insecurity and higher morbidity and mortality. 807 01:05:33,619 --> 01:05:37,859 And in the wise cohort, we also looked at how food insecurity impacts T-cell activation 808 01:05:37,859 --> 01:05:39,799 and senescence. 809 01:05:39,799 --> 01:05:44,940 Peters et. al., found that food insecurity was significantly associated with increased activation 810 01:05:44,940 --> 01:05:52,789 of CD4 and CD8+T-cells, increased senescence, CD8+T-cells and decreased post-stimulation 811 01:05:52,789 --> 01:05:59,799 CD4 and CD8+T-cells in adjusted analyses and similar to the last paper, the effects 812 01:05:59,799 --> 01:06:03,400 also persisted even among those with well-controlled HIV. 813 01:06:03,400 --> 01:06:08,680 Turning to the last pathway, we know that food insecurity impacts cardiometabolic health 814 01:06:08,680 --> 01:06:14,430 through the adoption of unhealthful health behaviors. So this can include poor diet, 815 01:06:14,430 --> 01:06:20,010 low physical activity, smoking, medication adherence and overall poor engagement and 816 01:06:20,010 --> 01:06:21,010 care. 817 01:06:21,010 --> 01:06:27,020 Hunger, so which is defined as the uneasy or painful sensation caused by a lack of food 818 01:06:27,020 --> 01:06:31,560 or by the recurrent and involuntary lack of access to food, can really drive people to 819 01:06:31,560 --> 01:06:33,690 adopt coping strategies to avoid it. 820 01:06:33,690 --> 01:06:38,470 And these strategies can include things like eating low-cost and highly filling foods that 821 01:06:38,470 --> 01:06:42,690 are calorically dense but nutrient poor, putting limited money towards food rather than towards 822 01:06:42,690 --> 01:06:48,920 medical care, and also binge eating when food is available in anticipation of future food 823 01:06:48,920 --> 01:06:54,500 challenges and all of these coping behaviors then both increase the risk of diet sensitive 824 01:06:54,500 --> 01:07:00,520 diseases like diabetes and hypertension, and then lead to worse outcomes once affected. 825 01:07:00,520 --> 01:07:05,079 Starting with diet quality, studies show that food insecurity leads to poor diet quality 826 01:07:05,079 --> 01:07:10,210 in both adults and children, however, results are not consistent across studies. 827 01:07:10,210 --> 01:07:18,049 For example, in this systematic review of 26 U.S. studies comprising 170 unique associations 828 01:07:18,049 --> 01:07:22,770 between food insecurity and diet quality, 29 percent of associations were found to be 829 01:07:22,770 --> 01:07:24,250 adverse and the majority of associations were not significant. 830 01:07:24,250 --> 01:07:30,859 And this may be in part related to the expense and challenges in measuring diet quality in 831 01:07:30,859 --> 01:07:32,100 epidemiologic study. 832 01:07:32,100 --> 01:07:39,950 Diet and poor nutrition, in turn, have important implications for cardiometabolic disease. 833 01:07:39,950 --> 01:07:46,609 So a study using nationally representative enhanced data by Micah et. al., found over 700,000 834 01:07:46,609 --> 01:07:52,500 deaths from cardiometabolic disease, with more than 45 percent of these deaths associated 835 01:07:52,500 --> 01:07:54,359 with poor nutritional intake. 836 01:07:54,359 --> 01:08:01,290 8.5 percent of cardiometabolic deaths were attributable to low nut and seed intake, 8.2 837 01:08:01,290 --> 01:08:08,970 percent to high processed meat consumption, 7.6 percent to low vegetable intake and 7.4 838 01:08:08,970 --> 01:08:11,340 percent to high sugar sweetened beverages. 839 01:08:11,340 --> 01:08:18,520 Aside from diet, food insecurity is also associated with smoking and lower physical activity, 840 01:08:18,520 --> 01:08:21,480 which confers risk for cardiovascular disease. 841 01:08:21,480 --> 01:08:29,690 For example, a study using a nationally representative sample of almost 5,000 adults by total, so 842 01:08:29,690 --> 01:08:34,160 they found that those with food insecurity had 16 percent lower odds of having adequate 843 01:08:34,160 --> 01:08:39,850 physical activity and in the Weiser cohort, we found a dose-dependent relationship 844 01:08:39,850 --> 01:08:45,560 between food insecurity and smoking, and specifically, participants with very low food security had 845 01:08:45,560 --> 01:08:51,830 approximately 2.3 times the odds of smoking compared to people with high food security. 846 01:08:51,830 --> 01:08:56,850 Food insecurity also interferes with adherence to treatment and care recommendations, so 847 01:08:56,850 --> 01:09:03,600 in a large study by Herman et al., using National Health Interview Survey data from over 65,000 848 01:09:03,600 --> 01:09:10,650 adults under the age of 65, a dose-dependent relationship was found between food insecurity 849 01:09:10,650 --> 01:09:13,370 and cost-related medication underuse. 850 01:09:13,370 --> 01:09:19,360 For example, those experiencing severe food insecurity had 3.7 times the odds of skipping 851 01:09:19,360 --> 01:09:25,750 their medications, 3.8 times the odds of taking less medication than prescribed, four times the 852 01:09:25,750 --> 01:09:30,870 odds of being delayed in filling their prescriptions and over four times the odds of not being able 853 01:09:30,870 --> 01:09:32,799 to afford the medication at all. 854 01:09:32,799 --> 01:09:36,120 And you can see that the odds of having at least one of these five outcomes was over 855 01:09:36,120 --> 01:09:41,250 three times greater among people who are severely food insecure. 856 01:09:41,250 --> 01:09:47,880 Similarly, looking specifically at HIV care and management, so in a recent systematic 857 01:09:47,880 --> 01:09:53,650 review from Singer in our group, we found a consistent association between food insecurity 858 01:09:53,650 --> 01:09:58,460 and antiretroviral non-adherence in all but three of the 19 studies that we looked at. 859 01:09:58,460 --> 01:10:04,820 And this was even after adjusting for socioeconomic status and other known barriers to adherence. 860 01:10:04,820 --> 01:10:10,230 So in conclusion, we’ve seen that food insecurity and poor cardiometabolic health interact in 861 01:10:10,230 --> 01:10:12,210 a vicious cycle. 862 01:10:12,210 --> 01:10:17,239 Food insecurity worsens cardiometabolic health through several key pathways, and these include 863 01:10:17,239 --> 01:10:23,350 worse mental health and stress responses, immune activation and inflammation, and changes 864 01:10:23,350 --> 01:10:24,790 in health behaviors. 865 01:10:24,790 --> 01:10:31,060 There are many points of intervention to interrupt this vicious cycle. 866 01:10:31,060 --> 01:10:35,550 Interventions targeted to these pathways can really improve food insecurity and address 867 01:10:35,550 --> 01:10:40,440 multiple health problems simultaneously. 868 01:10:40,440 --> 01:10:42,460 Thank you very much. 869 01:10:42,460 --> 01:10:50,260 DR. ANGELA ODOMS-YOUNG: That is excellent. 870 01:10:50,260 --> 01:10:53,970 Thank you so much for these excellent presentations. 871 01:10:53,970 --> 01:11:01,760 Now we’re going to move into our Q&A. We’ve already received a lot of good questions for 872 01:11:01,760 --> 01:11:09,540 our speakers and I’m going to try to get as many as I can in the time allotted because 873 01:11:09,540 --> 01:11:14,310 we shift to the break at 2:05. 874 01:11:14,310 --> 01:11:16,909 The first question is for Dr. Abelev. 875 01:11:16,909 --> 01:11:26,440 It’s exciting to see this shift to nutrition security, and I’m wondering how we can operationalize 876 01:11:26,440 --> 01:11:27,850 this term. 877 01:11:27,850 --> 01:11:33,830 We have found specific and consistent nutrient intake deficits in urban SNAP recipients, 878 01:11:33,830 --> 01:11:41,040 these deficits confer an informatory burden that can promote chronic disease and immune 879 01:11:41,040 --> 01:11:42,040 responses. 880 01:11:42,040 --> 01:11:46,370 And so the question is figuring out how do we operationalize nutrition security? 881 01:11:46,370 --> 01:11:50,190 DR. MELISSA ABELEV: Yeah, can you hear me? 882 01:11:50,190 --> 01:11:52,100 DR. ANGELA ODOMS-YOUNG: Yes. 883 01:11:52,100 --> 01:11:53,370 DR. MELISSA ABELEV: Yeah, okay. 884 01:11:53,370 --> 01:11:59,620 Yeah, it’s a great question, I think one of the big things that...one of the important 885 01:11:59,620 --> 01:12:02,840 things that we’ve done is the review of the Thrifty Food Plan, right? 886 01:12:02,840 --> 01:12:09,310 In that, really looking at what does it take in order for people to have access to meeting 887 01:12:09,310 --> 01:12:10,370 the dietary guidelines. 888 01:12:10,370 --> 01:12:18,860 And so within the mathematical optimization model, the key factors that are the inputs 889 01:12:18,860 --> 01:12:23,179 into the model are looking at the dietary guidelines and the food patterns, as well 890 01:12:23,179 --> 01:12:28,900 as the dietary reference intakes and really saying, you know, what is it that families 891 01:12:28,900 --> 01:12:35,330 need in order to be able to eat healthfully? And then aligning that with store scanner 892 01:12:35,330 --> 01:12:37,610 data that is 893 01:12:37,610 --> 01:12:45,690 from stores at the scanner level to go...to...sorry, inform the cost of the groceries, and 894 01:12:45,690 --> 01:12:52,610 then ask when you align those things, what does it cost for a family to be able to purchase 895 01:12:52,610 --> 01:12:56,409 a diet that aligns with dietary guidelines? 896 01:12:56,409 --> 01:13:03,280 And so then by doing that re-examination, we see that it, in fact, necessitated an increase 897 01:13:03,280 --> 01:13:04,980 in the SNAP benefit. 898 01:13:04,980 --> 01:13:11,440 And so that reevaluation is a really key part there to say, do people have the resources 899 01:13:11,440 --> 01:13:16,750 they need in order to access the dietary guidelines? 900 01:13:16,750 --> 01:13:22,750 And so that’s a really key part when you overlay that, as I said, there’s a pretty 901 01:13:22,750 --> 01:13:27,730 significant amount in the SNAP budget that goes out to the states, through community 902 01:13:27,730 --> 01:13:34,610 partners, for nutrition education in order to help people know you have the resources 903 01:13:34,610 --> 01:13:40,290 now, what is purchasing and preparing a healthy diet and making sure that people have the 904 01:13:40,290 --> 01:13:46,520 information as well as communities have the resources for community-based PSE strategies 905 01:13:46,520 --> 01:13:53,710 to say how do we help inform and shape an environment where people are able to access 906 01:13:53,710 --> 01:13:55,070 healthy choices? 907 01:13:55,070 --> 01:13:59,520 So those are the types of things. 908 01:13:59,520 --> 01:14:04,330 And as I mentioned, some of the other policy things that USDA is pursuing through the WIC 909 01:14:04,330 --> 01:14:09,940 390 fund, making sure that people know that they continue to be eligible. 910 01:14:09,940 --> 01:14:15,920 As I mentioned, there’s a huge drop-off after the first birthday. We’ve done a significant 911 01:14:15,920 --> 01:14:20,199 amount of research on retention and WIC and why people leave. 912 01:14:20,199 --> 01:14:25,760 One of the key reasons is they don’t necessarily realize that they remain eligible. 913 01:14:25,760 --> 01:14:29,910 WIC participants are also a very kind group of people. 914 01:14:29,910 --> 01:14:36,880 And oftentimes they don’t realize that it’s not a pie, the people who are eligible can 915 01:14:36,880 --> 01:14:37,880 continue. 916 01:14:37,880 --> 01:14:40,900 And so they think, “Well, I don’t think I need it as much anymore and so I want to 917 01:14:40,900 --> 01:14:42,790 make sure other people have access to it.” 918 01:14:42,790 --> 01:14:48,040 So a key part of that is helping folks realize you both can be a part of it. 919 01:14:48,040 --> 01:14:50,310 You don’t have to leave so that other people can get in. 920 01:14:50,310 --> 01:14:54,650 And so those are the types of things that we’re looking at through the WIC 390 funds, 921 01:14:54,650 --> 01:15:01,480 innovation strategies to make sure that people know of the resources that they have. 922 01:15:01,480 --> 01:15:07,639 And then as I said, looking at SNAP online, WIC online, things that some of us take for 923 01:15:07,639 --> 01:15:13,760 granted in being able to purchase groceries in many different ways, in ways that are convenient 924 01:15:13,760 --> 01:15:20,580 to working parents and working environment and so forth, making sure that FNS participants 925 01:15:20,580 --> 01:15:26,460 have access to those things too, so that it’s easy to access these important nutrition resources. 926 01:15:26,460 --> 01:15:28,510 DR. ANGELA ODOMS-YOUNG: Thanks. 927 01:15:28,510 --> 01:15:32,310 That actually leads me to a follow up question. 928 01:15:32,310 --> 01:15:37,840 One of the questions that came in was about access to SNAP online. 929 01:15:37,840 --> 01:15:44,070 What is the percent of participants that have a reliable access to online purchasing in 930 01:15:44,070 --> 01:15:45,070 SNAP? 931 01:15:45,070 --> 01:15:52,310 DR. MELISSA ABELAV: At this point, it’s 97 percent of SNAP participants have access to online purchasing. 932 01:15:52,310 --> 01:15:58,270 DR. ANGELA ODOMS-YOUNG: OK, great. 933 01:15:58,270 --> 01:15:59,270 Thank you. 934 01:15:59,270 --> 01:16:07,219 I’m just looking through, there’s a couple of questions that came in related to Dr. Weiser’s 935 01:16:07,219 --> 01:16:12,570 presentation about the pathways between food insecurity and cardiometabolic health. 936 01:16:12,570 --> 01:16:21,150 There’s two questions—I’m going to kind of merge them together because they’re related: 937 01:16:21,150 --> 01:16:26,869 Have these pathways been well established or are most of these studies cross-sectional? 938 01:16:26,869 --> 01:16:34,040 And then a second question is related to the severity of the negative outcome in individuals 939 01:16:34,040 --> 01:16:41,610 that have periods of food insecurity in life, but not consistent experiences of food insecurity. 940 01:16:41,610 --> 01:16:49,390 So they may have more inconsistent periods where they’re food insecure vs. this 941 01:16:49,390 --> 01:16:52,120 sort of persistent food insecurity. 942 01:16:52,120 --> 01:16:56,790 So, overall, what do we know about these pathways? 943 01:16:56,790 --> 01:17:02,520 Are they well-established in the severity of outcomes when people face different conditions 944 01:17:02,520 --> 01:17:03,760 as it relates to food insecurity? 945 01:17:03,760 --> 01:17:05,760 DR. SHERI WEISER: Thank you very much. 946 01:17:05,760 --> 01:17:11,690 So, there's a...I presented a lot of different studies and certainly some of the population-based 947 01:17:11,690 --> 01:17:17,969 studies I presented using the large datasets were cross-sectional, where we really...just associational 948 01:17:17,969 --> 01:17:26,890 studies, so we can’t say much about causality in our work and there’s also a lot of longitudinal 949 01:17:26,890 --> 01:17:34,150 studies out there where you are able to look at antecedents food insecurity, predicting 950 01:17:34,150 --> 01:17:36,650 later cardiometabolic health. 951 01:17:36,650 --> 01:17:42,760 And we definitely have found that earlier food insecurity is predictive of later health 952 01:17:42,760 --> 01:17:43,760 outcomes. 953 01:17:43,760 --> 01:17:47,960 So that may strengthen the plausibility of this association. 954 01:17:47,960 --> 01:17:55,030 We also find, to the point of the intensity of food insecurity, that people who have more 955 01:17:55,030 --> 01:18:03,020 severe food insecurity, we see dose-response relationships across so many of the studies 956 01:18:03,020 --> 01:18:06,989 in our research and that of others where you see people with more severe food insecurity 957 01:18:06,989 --> 01:18:15,500 have worse mental health problems, greater nutritional deficits, and greater...worse access to 958 01:18:15,500 --> 01:18:21,760 care, greater acute care utilization and increased morbidity and mortality. 959 01:18:21,760 --> 01:18:27,280 In terms of making the causal connection what we really need is intervention research, which 960 01:18:27,280 --> 01:18:30,590 we’re going to be hearing more about. 961 01:18:30,590 --> 01:18:38,070 But just as an example, in our research using medically tailored meals, working with Project 962 01:18:38,070 --> 01:18:43,760 Open Hand, we found that individuals who received medically tailored meals had decreases in 963 01:18:43,760 --> 01:18:49,040 depression and diabetes distress, improvement and adherence to treatment and care recommendations, 964 01:18:49,040 --> 01:18:50,870 and reduced acute care use among other mechanisms. 965 01:18:50,870 --> 01:18:58,160 And to your point about the sort of length, there’s sort of two more pieces to this. 966 01:18:58,160 --> 01:19:03,351 To the points about persistent food insecurity vs. one-time food insecurity. And while we 967 01:19:03,351 --> 01:19:09,060 haven’t evaluated this in our research over the long-term, we have evaluated it say, over 968 01:19:09,060 --> 01:19:15,040 the past year, and we find consistently again, across our studies, that people who have persistent 969 01:19:15,040 --> 01:19:21,040 food insecurity across multiple time points fare worse than people who just were food 970 01:19:21,040 --> 01:19:23,719 insecure at one point in time. 971 01:19:23,719 --> 01:19:28,800 And the last thing, just to clarify, is that we find food insecurity being associated with 972 01:19:28,800 --> 01:19:33,480 both disease acquisition and then worse outcomes once people are impacted. 973 01:19:33,480 --> 01:19:41,600 So for instance, with diabetes, we see worse adherence to treatment and care, higher hemoglobin 974 01:19:41,600 --> 01:19:47,560 A1c levels and many other worse outcomes, and an increased morbidity and mortality. 975 01:19:47,560 --> 01:19:52,930 DR. ANGELA ODOMS-YOUNG: Thank you so much, Dr. Weiser. 976 01:19:52,930 --> 01:19:56,950 There’s several questions that came in for Dr. Coleman-Jensen. 977 01:19:56,950 --> 01:20:03,870 The first question is related to the 2020 food insecurity prevalence estimates; 978 01:20:03,870 --> 01:20:07,190 Are they available for specific age groups? 979 01:20:07,190 --> 01:20:14,600 DR. ALISHA COLEMAN-JENSEN: In our annual report that presents all the statistics on food insecurity 980 01:20:14,600 --> 01:20:19,810 in 2020 that I referred to today, we do include statistics for households that have elderly 981 01:20:19,810 --> 01:20:22,010 members and households with children. 982 01:20:22,010 --> 01:20:30,100 So we do break out those two age groups separately, but we don’t go into detail, across the lifespan 983 01:20:30,100 --> 01:20:31,739 for each group. 984 01:20:31,739 --> 01:20:37,860 And we typically find that food insecurity is somewhat lower than the national average 985 01:20:37,860 --> 01:20:43,060 for elderly households and higher than the national average for households with children. 986 01:20:43,060 --> 01:20:49,350 DR. ANGELA ODOMS-YOUNG: This is a question about the various surveys. 987 01:20:49,350 --> 01:20:56,170 Does the food programs that are included in the surveys only include the federal food 988 01:20:56,170 --> 01:20:59,489 and nutrition assistance programs or any food programs? 989 01:20:59,489 --> 01:21:00,489 DR. 990 01:21:00,489 --> 01:21:02,739 COLEMAN-JENSEN: It depends on the survey. 991 01:21:02,739 --> 01:21:06,460 The current population survey of food security supplement, which is our source of federal 992 01:21:06,460 --> 01:21:15,159 food security statistics that we report on annually, asks questions about use of community 993 01:21:15,159 --> 01:21:19,900 nutrition assistance programs, such as food pantries and soup kitchens. 994 01:21:19,900 --> 01:21:26,040 So it depends on the various surveys, what specific questions they ask, but some of that 995 01:21:26,040 --> 01:21:29,660 information is available in the food security supplement. 996 01:21:29,660 --> 01:21:35,640 DR. ANGELA ODOMS-YOUNG: And the last question, as it relates to the food insecurity data, 997 01:21:35,640 --> 01:21:42,810 one of the attendees asked, "Why do you think the pandemic did not increase food insecurity 998 01:21:42,810 --> 01:21:46,370 rates compared to 2019 food insecurity rates? 999 01:21:46,370 --> 01:21:50,460 Was it due to expansion of SNAP and the provision of other resources?" 1000 01:21:50,460 --> 01:21:58,880 DR. ALISHA COLEMAN-JENSEN: I think more analysis is needed to understand fully the dynamics of food insecurity 1001 01:21:58,880 --> 01:22:01,110 during the pandemic. 1002 01:22:01,110 --> 01:22:09,500 We do know that in 2020, there were a lot of extra resources available to households, 1003 01:22:09,500 --> 01:22:13,889 both increases in nutrition assistance, as Melissa mentioned, and also increases in stimulus 1004 01:22:13,889 --> 01:22:16,929 payments, non-employment benefits, and the eviction moratorium. 1005 01:22:16,929 --> 01:22:22,199 All of those help to provide extra resources for families. 1006 01:22:22,199 --> 01:22:26,710 We know from previous research that increases in nutrition assistance and other benefits 1007 01:22:26,710 --> 01:22:29,230 do help to reduce food insecurity. 1008 01:22:29,230 --> 01:22:34,620 So it’s possible that, that was a factor during the pandemic as well. 1009 01:22:34,620 --> 01:22:38,580 DR. ANGELA ODOMS-YOUNG: Thank you so much, Dr. Coleman-Jensen. 1010 01:22:38,580 --> 01:22:43,050 We have a few additional questions that came in for Dr. Abelev. 1011 01:22:43,050 --> 01:22:49,830 The first presentation, you mentioned that over 800 flexibilities and waivers were created 1012 01:22:49,830 --> 01:22:51,670 throughout the pandemic. 1013 01:22:51,670 --> 01:22:57,730 With the creation of so many new guidelines, how was the information translated, for example, 1014 01:22:57,730 --> 01:23:01,500 to school districts, to ensure that they were educated? 1015 01:23:01,500 --> 01:23:04,440 DR. MELISSA ABELEV: Yeah. 1016 01:23:04,440 --> 01:23:10,270 We have a pretty mature communications channel to the local. 1017 01:23:10,270 --> 01:23:14,770 It’s called an SFA with the School Food Authority that are the... 1018 01:23:14,770 --> 01:23:19,420 for folks who aren’t familiar with the school meals programs, they’re run at the district 1019 01:23:19,420 --> 01:23:21,130 level through what’s called the School Food Authority, 1020 01:23:21,130 --> 01:23:24,610 and so we communicated that guidance to them in real time. 1021 01:23:24,610 --> 01:23:28,940 Essentially, as soon as it cleared, we sent it out through what’s called partner web, 1022 01:23:28,940 --> 01:23:34,610 out to the school districts, through our state partners, through our regional partners. 1023 01:23:34,610 --> 01:23:37,270 We also posted everything. 1024 01:23:37,270 --> 01:23:42,120 We had a commitment to try to post everything within 24 hours to our website. 1025 01:23:42,120 --> 01:23:49,580 And so every flexibility, every waiver, every adjustment was up on our website as well. 1026 01:23:49,580 --> 01:23:55,170 And so through multiple channels, we were trying to make sure that everybody had the information 1027 01:23:55,170 --> 01:23:56,540 in real time. 1028 01:23:56,540 --> 01:24:02,750 We also notify the Hill every time that we make a change, and so, those were also being 1029 01:24:02,750 --> 01:24:08,060 communicated out through congressional partners and such. 1030 01:24:08,060 --> 01:24:13,420 We tried very diligently to ensure that all operators had that information. 1031 01:24:13,420 --> 01:24:20,650 There were webinars that also, as things were happening, so that people could ask questions 1032 01:24:20,650 --> 01:24:22,110 and such. 1033 01:24:22,110 --> 01:24:25,030 So there was multiple channels. 1034 01:24:25,030 --> 01:24:33,170 DR. ANGELA ODOMS-YOUNG: Here’s a second question related to nutrition security and how it’s 1035 01:24:33,170 --> 01:24:34,630 being addressed in SNAP. 1036 01:24:34,630 --> 01:24:41,840 Dr. Abelev, can you talk a little bit about how the nutrition security piece is being 1037 01:24:41,840 --> 01:24:44,560 addressed throughout the SNAP program? 1038 01:24:44,560 --> 01:24:51,830 DR. MELISSA ABELEV: Yeah, and I think, as I mentioned, one of the key things that we looked at was in the update 1039 01:24:51,830 --> 01:24:56,850 of the Thrifty, really making sure that the resources were sufficient to really align 1040 01:24:56,850 --> 01:24:59,890 with the dietary standards and such. 1041 01:24:59,890 --> 01:25:03,080 And then the nutrition prevent... 1042 01:25:03,080 --> 01:25:07,820 Sorry...I’m going to stumble over my words. 1043 01:25:07,820 --> 01:25:14,219 The SNAP-Ed grant that we partner through part of a SNAP-Ed consortium throughout the 1044 01:25:14,219 --> 01:25:19,170 country, the Center for Nutrition and Policy Promotion, which is a part of the Food and 1045 01:25:19,170 --> 01:25:23,120 Nutrition Service and is in charge of the Thrifty Re-Evaluation. 1046 01:25:23,120 --> 01:25:29,460 They also lead the Dietary Guidelines for Americans Evaluation in partnership with HHS 1047 01:25:29,460 --> 01:25:31,320 every few years. 1048 01:25:31,320 --> 01:25:40,270 They also have the MyPlate dietary guidance and a number of nutrition education materials 1049 01:25:40,270 --> 01:25:45,390 through different apps and through different marketing materials so that... 1050 01:25:45,390 --> 01:25:51,280 the guidelines, which are highly scientific are then translated into messaging that is 1051 01:25:51,280 --> 01:25:57,850 focused on consumers and being able to understand how to purchase and prepare those foods. 1052 01:25:57,850 --> 01:26:04,710 So it’s through a multi-pronged effort through both the promotion activities we do at the 1053 01:26:04,710 --> 01:26:17,370 federal level, within our partnerships with states and local through those SNAP Nutrition Education partnerships and grants around the country. 1054 01:26:17,370 --> 01:26:20,639 DR. ANGELA ODOMS-YOUNG: Thank you. 1055 01:26:20,639 --> 01:26:28,679 One of the things that came out, Dr. Coleman-Jensen, in the data that you presented with 1056 01:26:28,679 --> 01:26:34,850 the focus on disparities and equity as part of this session, you talked a little bit about 1057 01:26:34,850 --> 01:26:40,290 some differences that you see in the 2020 data. 1058 01:26:40,290 --> 01:26:45,330 Can you talk a little bit more about that and maybe highlight...I know you can't, you don’t 1059 01:26:45,330 --> 01:26:51,890 have the reasons why, but I know both you and Dr. Weiser talked a little bit about some 1060 01:26:51,890 --> 01:26:52,900 of the pathways? 1061 01:26:52,900 --> 01:26:59,060 Can you talk a little bit about how and why you think some of these inequities exist? 1062 01:26:59,060 --> 01:27:02,090 DR. ALISHA COLEMAN-JENSEN: Sure. 1063 01:27:02,090 --> 01:27:04,100 Thanks, Angela. 1064 01:27:04,100 --> 01:27:11,500 We found that in 2020, food insecurity increased for all household with children, which I 1065 01:27:11,500 --> 01:27:12,500 mentioned. 1066 01:27:12,500 --> 01:27:18,310 Food insecurity increased for households with Black, non-Hispanic reference person. 1067 01:27:18,310 --> 01:27:23,969 Again, a reference person is sort of a survey term, but it’s an adult in the household 1068 01:27:23,969 --> 01:27:26,960 who’s name the housing unit is owned or rented. 1069 01:27:26,960 --> 01:27:30,890 You can think of a reference person as a head of households. 1070 01:27:30,890 --> 01:27:34,550 For a married couple or cohabiting partner, it can be either adult. 1071 01:27:34,550 --> 01:27:39,570 So households with a Black, non-Hispanic reference person saw a statistically significant increase 1072 01:27:39,570 --> 01:27:45,460 in food insecurity in 2020. 1073 01:27:45,460 --> 01:27:50,790 The higher prevalence of food insecurity for households headed by Black, non-Hispanic adults 1074 01:27:50,790 --> 01:27:55,670 and by Hispanic adults is a consistent finding over time. 1075 01:27:55,670 --> 01:27:59,320 Over time, we’ve seen that these households have higher food insecurity rates than households 1076 01:27:59,320 --> 01:28:01,730 headed by white, non-Hispanic adults. 1077 01:28:01,730 --> 01:28:07,030 There could be a number of factors related to these differences. 1078 01:28:07,030 --> 01:28:09,920 One is income differences across groups. 1079 01:28:09,920 --> 01:28:18,110 We know that poverty rates for example, are higher for these groups and our statistics 1080 01:28:18,110 --> 01:28:21,710 don’t account for differences by income or anything like that. 1081 01:28:21,710 --> 01:28:31,210 So, those are income differences and other disparities in wealth could play a role. 1082 01:28:31,210 --> 01:28:38,530 There’s also differences as others have alluded to, with regard to health disparities 1083 01:28:38,530 --> 01:28:42,139 across groups that may...that could possibly play a factor as well. 1084 01:28:42,139 --> 01:28:47,981 So as you mentioned, we can’t say for certain why food insecurity increased for some groups 1085 01:28:47,981 --> 01:28:53,980 in 2020 and not others, but there are a sort of lingering disparities across groups that 1086 01:28:53,980 --> 01:28:59,080 were not new this year, but that have been consistent over time. 1087 01:28:59,080 --> 01:29:00,660 DR. ANGELA ODOMS-YOUNG: Thank you. 1088 01:29:00,660 --> 01:29:10,199 There is a question specifically related to people with disabilities or with chronic conditions; 1089 01:29:10,199 --> 01:29:15,660 In assessing food insecurity, are they also assessing the relationship between disability 1090 01:29:15,660 --> 01:29:22,080 and food insecurity such as when a disabled or chronically ill individual may have food 1091 01:29:22,080 --> 01:29:27,501 in the house, but not the food they need, or might be unable to prepare or consume food 1092 01:29:27,501 --> 01:29:29,489 because of their disability. 1093 01:29:29,489 --> 01:29:37,199 DR. ALISHA COLEMAN-JENSEN: So we do...I can answer some of that. 1094 01:29:37,199 --> 01:29:40,050 So we do look at food insecurity by disability status, and we’ve done previous research 1095 01:29:40,050 --> 01:29:41,050 on that. 1096 01:29:41,050 --> 01:29:46,660 And when we have found that the disabilities are a significant risk factor for food insecurity, 1097 01:29:46,660 --> 01:29:51,070 households that include any adult with a disability have much higher food insecurity rates than 1098 01:29:51,070 --> 01:29:56,690 those that do not include adults with disabilities. 1099 01:29:56,690 --> 01:30:03,159 Primarily when we’re looking at food insecurity among adults or households that include adults 1100 01:30:03,159 --> 01:30:06,620 with disabilities, this again is related to economic resources. 1101 01:30:06,620 --> 01:30:12,710 In terms of...the definition of food insecurity doesn’t change when we examine food insecurity 1102 01:30:12,710 --> 01:30:13,710 and disabilities. 1103 01:30:13,710 --> 01:30:20,200 Of course, there may be a factor beyond income through which disabilities might affect food 1104 01:30:20,200 --> 01:30:21,200 insecurity. 1105 01:30:21,200 --> 01:30:27,480 One way to think about it though, is that if disabilities make food insecurity a problem 1106 01:30:27,480 --> 01:30:34,070 in part, because people with disabilities have more difficulty going to the store or 1107 01:30:34,070 --> 01:30:38,639 preparing meals or things like that, income may be able to overcome those challenges. 1108 01:30:38,639 --> 01:30:44,900 So if households are still experiencing those challenges, one underlying assumption is that 1109 01:30:44,900 --> 01:30:50,210 they don’t have the resources available to overcome, to pay for somebody to do those 1110 01:30:50,210 --> 01:30:54,560 things for them or to buy prepared meals and things of that nature. 1111 01:30:54,560 --> 01:31:00,540 But it’s certainly true that disabilities are an important risk factor for food insecurity. 1112 01:31:00,540 --> 01:31:06,380 And we’ve looked at...not disabilities across the range, the disabilities that are related 1113 01:31:06,380 --> 01:31:12,950 to employment in terms of people who are reporting that they’re disabled and are unable to 1114 01:31:12,950 --> 01:31:13,950 work. 1115 01:31:13,950 --> 01:31:18,560 Disabilities related to mobility, sensory impairments, and also mental health disabilities. 1116 01:31:18,560 --> 01:31:26,270 And all of those different types of disabilities are related to an increased risk of food insecurity. 1117 01:31:26,270 --> 01:31:32,139 DR. SHERI WEISER: And I just wanted to add one thing to that, which is just that several food security 1118 01:31:32,139 --> 01:31:41,544 programs and food delivery services really do take into account the role that disability 1119 01:31:41,544 --> 01:31:46,520 plays in a worsening food insecurity and nutrition security. 1120 01:31:46,520 --> 01:31:52,320 And so have delivery options of either medically tailored meals or groceries or prepared meals 1121 01:31:52,320 --> 01:31:57,960 in some other fashion for people with disabilities. 1122 01:31:57,960 --> 01:32:02,270 DR. ANGELA ODOMS-YOUNG: Thank you. 1123 01:32:02,270 --> 01:32:08,940 We have one question that just came in for Dr. Coleman-Jensen. 1124 01:32:08,940 --> 01:32:14,810 Dr. Coleman-Jensen had a slide that showed approximately 45 percent of food insecure 1125 01:32:14,810 --> 01:32:18,850 households did not participate in food assistance programs. 1126 01:32:18,850 --> 01:32:21,699 Do we know if they receive any support? 1127 01:32:21,699 --> 01:32:30,790 Could you talk a little bit more about this 45 percent that are not participating in food 1128 01:32:30,790 --> 01:32:35,760 and nutrition assistance programs or our federal food and nutrition assistance programs? 1129 01:32:35,760 --> 01:32:37,760 DR. ALISHA COLEMAN-JENSEN: Sure. 1130 01:32:37,760 --> 01:32:39,660 That’s a really important question. 1131 01:32:39,660 --> 01:32:46,270 And the caveat to that slide and those estimates is that those are self-reported survey data. 1132 01:32:46,270 --> 01:32:50,810 And we know that participation in federal programs is underreported as survey data. 1133 01:32:50,810 --> 01:32:56,350 So some percentage of those households may have been participating but not have reported 1134 01:32:56,350 --> 01:32:57,610 their participation. 1135 01:32:57,610 --> 01:33:02,770 Some households may choose not to participate for whatever reasons. 1136 01:33:02,770 --> 01:33:06,880 Some may be ineligible if their income is above threshold. 1137 01:33:06,880 --> 01:33:12,370 Or for example, if their household composition, if they don’t have children, they might 1138 01:33:12,370 --> 01:33:15,510 not be eligible for school meals of course. 1139 01:33:15,510 --> 01:33:20,650 And for WIC, depending on the composition of their households. 1140 01:33:20,650 --> 01:33:26,199 It’s important to note that the data can be underreported. 1141 01:33:26,199 --> 01:33:33,310 So I wouldn’t say that that’s a hard and fast percentage of...for sure that 45 percent 1142 01:33:33,310 --> 01:33:36,610 are not participating in those programs. 1143 01:33:36,610 --> 01:33:42,130 And I will say that research that’s able to account for selection into those programs. 1144 01:33:42,130 --> 01:33:47,140 So there’s an open question about, well, if all these people are participating in 1145 01:33:47,140 --> 01:33:50,100 nutrition assistance, why might they still be experiencing food insecurity? 1146 01:33:50,100 --> 01:33:54,739 But I think it’s important to note that research that is able to account for the self-selection, 1147 01:33:54,739 --> 01:33:59,460 into nutrition assistance programs shows that people who are, that participation in 1148 01:33:59,460 --> 01:34:03,390 those programs does help to reduce food insecurity. 1149 01:34:03,390 --> 01:34:08,219 And when I say, what I mean by self-selection is that people who really need the programs 1150 01:34:08,219 --> 01:34:09,219 are more likely to participate. 1151 01:34:09,219 --> 01:34:14,590 And if you really need those nutrition assistance programs, you may be experiencing food hardship, 1152 01:34:14,590 --> 01:34:15,590 right? 1153 01:34:15,590 --> 01:34:21,390 But we do find that when we’re able to account for that, for the selection into the programs, 1154 01:34:21,390 --> 01:34:25,230 that nutrition assistance does help to reduce food insecurity. 1155 01:34:25,230 --> 01:34:30,920 And especially when we examine the impact of the size of benefits, we find that the 1156 01:34:30,920 --> 01:34:33,560 larger benefits help to reduce food insecurity. 1157 01:34:33,560 --> 01:34:40,290 DR. SHERI WEISER: I wonder if I could add something there, and...which is basically that in our 1158 01:34:40,290 --> 01:34:48,170 research, we have also found that stigma and shame related to food insecurity, definitely 1159 01:34:48,170 --> 01:34:56,179 impeded participation, and another big factor in our qualitative work has been perceptions 1160 01:34:56,179 --> 01:35:01,750 of discrimination and structural racism similar to, in the health care setting in all federal 1161 01:35:01,750 --> 01:35:04,650 poverty and disability services. 1162 01:35:04,650 --> 01:35:13,050 People have reported experiencing similar things and that sometimes impedes their participation. 1163 01:35:13,050 --> 01:35:16,489 DR. ANGELA ODOMS-YOUNG: Thank you so much. 1164 01:35:16,489 --> 01:35:24,170 Thank you to the audience for such great questions and to our panelists for the thoughtful feedback 1165 01:35:24,170 --> 01:35:25,630 and responses. 1166 01:35:25,630 --> 01:35:32,940 We are going to take a quick break followed by a moderated network chat in the network 1167 01:35:32,940 --> 01:35:42,300 lounge. You have until 2:20 EST for the break and the chat discussion before the next session begins. 1168 01:35:42,300 --> 01:35:46,930 And so, I just, again, I would like to thank our speakers. 1169 01:35:46,930 --> 01:35:53,650 It was a phenomenal panel and really brought up-to-date information, both what has happened 1170 01:35:53,650 --> 01:35:59,679 since the pandemic started, as far as our federal food and nutrition assistance programs 1171 01:35:59,679 --> 01:36:06,940 responding, the current data, and then also understanding more about the pathways and mechanisms, 1172 01:36:06,940 --> 01:36:11,350 so we can understand more about the impacts of food insecurity. 1173 01:36:11,350 --> 01:36:14,920 And so thank you so much. 1174 01:36:14,920 --> 01:36:18,590 DR. ANGELA ODOMS-YOUNG: Welcome back. 1175 01:36:18,590 --> 01:36:25,270 We are going to start with session two, which is a state of the science regarding research 1176 01:36:25,270 --> 01:36:27,230 gaps and opportunities. 1177 01:36:27,230 --> 01:36:33,010 I hope you were able to take advantage of the moderating network chat. 1178 01:36:33,010 --> 01:36:40,980 As well as interact with colleagues, look at what's happening within the platform. 1179 01:36:40,980 --> 01:36:43,170 I know we've moved to this virtual world. 1180 01:36:43,170 --> 01:36:47,909 And so it's exciting that we have the technology to be able to interact. 1181 01:36:47,909 --> 01:36:50,869 So we're going to talk about the state of the science. 1182 01:36:50,869 --> 01:36:57,739 And the objective of this session is to discuss current knowledge of disparities and food insecurity, 1183 01:36:57,739 --> 01:37:00,610 and trends within respective demographic groups. 1184 01:37:00,610 --> 01:37:06,250 Describe the association of food insecurity with health outcomes and key drivers. 1185 01:37:06,250 --> 01:37:10,730 And then identify gaps in knowledge and research opportunities. 1186 01:37:10,730 --> 01:37:17,990 We are very excited to have Dr. Charlotte Pratt, program director at the National Heart, Lung, 1187 01:37:17,990 --> 01:37:23,060 and Blood Institute, who will serve as our moderator for this panel. 1188 01:37:23,060 --> 01:37:28,199 Her experience and expertise in nutrition and obesity research throughout the life course 1189 01:37:28,199 --> 01:37:30,200 will really help shape the discussion. 1190 01:37:30,200 --> 01:37:33,660 And so, Charlotte, I'm going to turn it over to you. 1191 01:37:33,660 --> 01:37:38,770 DR. CHARLOTTE PRATT: Thank you very much, Angela. 1192 01:37:38,770 --> 01:37:45,770 I'm really very delighted to be part of... 1193 01:37:45,770 --> 01:37:47,010 Thank you very much, Angela. 1194 01:37:47,010 --> 01:37:52,750 I'm really, very delighted to be moderating this session. 1195 01:37:52,750 --> 01:37:59,590 I also want to welcome everyone to this panel discussion. 1196 01:37:59,590 --> 01:38:07,520 In the previous session, our speakers discussed food insecurity in the context of food and 1197 01:38:07,520 --> 01:38:08,580 nutrition programs. 1198 01:38:08,580 --> 01:38:17,210 The USDA Nutrition Program, measurement of food insecurity, the pathophysiology of food 1199 01:38:17,210 --> 01:38:20,520 insecurity, and chronic diseases. 1200 01:38:20,520 --> 01:38:28,580 And now we'll be moving on to discuss disparities in food insecurity and highlight those groups 1201 01:38:28,580 --> 01:38:31,540 most at risk for food insecurity. 1202 01:38:31,540 --> 01:38:38,580 Our first panelist will be Dr. Craig Gundersen of Baylor University, 1203 01:38:38,580 --> 01:38:45,030 who will be speaking about food insecurity in often overlooked populations. 1204 01:38:45,030 --> 01:38:55,849 He will then be followed by Dr. Valerie Blue Bird Jernigan of Oklahoma State University, 1205 01:38:55,849 --> 01:39:00,500 who will discuss food insecurity among Native American communities. 1206 01:39:00,500 --> 01:39:08,880 Our third and final speaker for this session will be Dr. Lorrene Ritchie of the University 1207 01:39:08,880 --> 01:39:09,980 of California, 1208 01:39:09,980 --> 01:39:18,150 who will discuss food insecurity across the lifespan and the role of food insecurity among 1209 01:39:18,150 --> 01:39:21,300 pregnant women, children, and adults. 1210 01:39:21,300 --> 01:39:28,901 Please help me welcome our panel discussants. 1211 01:39:32,369 --> 01:39:37,658 DR. CRAIG GUNDERSEN: Good afternoon, everyone. 1212 01:39:37,658 --> 01:39:41,560 My name is Craig Gundersen. I'm from Baylor University. 1213 01:39:41,560 --> 01:39:46,630 I want to thank everybody very much for being here in attendance at this important conference, 1214 01:39:46,630 --> 01:39:51,592 and in particular, I wanted to thank Angela and Karen for giving me the opportunity to 1215 01:39:51,592 --> 01:39:54,080 talk with all of you today. 1216 01:39:54,080 --> 01:40:00,580 So there's a huge literature that's looked at food insecurity in the United States, you 1217 01:40:00,580 --> 01:40:02,429 know, literally hundreds of papers on this topic. 1218 01:40:02,429 --> 01:40:07,960 And it's pointed out a lot of different areas where people...there's different population 1219 01:40:07,960 --> 01:40:12,929 group that have higher or much higher probabilities of being food insecure than the general population. 1220 01:40:12,929 --> 01:40:16,020 But unfortunately, despite all this literature, a lot of these groups are still being overlooked. 1221 01:40:16,020 --> 01:40:23,389 So what I want to talk today about is food insecurity amongst these groups and these overlooked 1222 01:40:23,389 --> 01:40:24,389 groups. 1223 01:40:24,389 --> 01:40:27,570 So I could talk about, you know, five different groups, when we talk about this. 1224 01:40:27,570 --> 01:40:32,599 But then when you turn to is relatively a simple and straightforward solution to addressing 1225 01:40:32,599 --> 01:40:38,190 food insecurity and almost completely eliminate food insecurity amongst these overlooked groups. 1226 01:40:38,190 --> 01:40:41,719 But more broadly amongst the full population. 1227 01:40:41,719 --> 01:40:43,719 OK. So. 1228 01:40:43,719 --> 01:40:47,910 The first overlooked group is American Indians in our country. 1229 01:40:47,910 --> 01:40:55,090 The food insecurity rates are substantially higher than any other race/ethnicity group. 1230 01:40:55,090 --> 01:41:01,080 And I'm not going to talk much about them today because I know Valerie is going to be covering 1231 01:41:01,080 --> 01:41:02,240 the challenges facing American Indians. 1232 01:41:02,240 --> 01:41:04,969 This map is Feeding America's Map The Meal Gap. 1233 01:41:04,969 --> 01:41:08,239 Which has county-level estimates of food insecurity for all counties in the United 1234 01:41:08,239 --> 01:41:09,239 States. 1235 01:41:09,239 --> 01:41:13,450 All congressional districts are broken and also broken down by children and all households. 1236 01:41:13,450 --> 01:41:18,250 But when you look at this map is what you see as the standard stories high rates of 1237 01:41:18,250 --> 01:41:19,429 food insecurity in Appalachia. 1238 01:41:19,429 --> 01:41:23,159 High rates of food insecurity across the parts of the South. 1239 01:41:23,159 --> 01:41:26,530 One other thing that's most...that really points out the challenges facing American Indians 1240 01:41:26,530 --> 01:41:31,580 is if you look at a state like North Dakota or a state like Montana or a state like South 1241 01:41:31,580 --> 01:41:32,920 Dakota. 1242 01:41:32,920 --> 01:41:36,270 Overall, relatively low rates of food insecurity. 1243 01:41:36,270 --> 01:41:41,080 However, in these counties, which all contain American...American Indian reservations, 1244 01:41:41,080 --> 01:41:43,130 you find these incredibly higher rates. 1245 01:41:43,130 --> 01:41:49,909 Similarly, here in South Dakota, or looking at Arizona as these high rates of food insecurity 1246 01:41:49,909 --> 01:41:53,679 on the eastern edge of the state, which are where American Indian reservations are. 1247 01:41:53,679 --> 01:41:55,480 Or for that matter, looking at Alaska and Alaska Native communities. 1248 01:41:55,480 --> 01:42:01,460 So this is the first group with really high rates of food insecurity that are often overlooked 1249 01:42:01,460 --> 01:42:04,750 in our discussions about food insecurity. 1250 01:42:04,750 --> 01:42:08,100 The second group is black persons in the Upper Midwest. 1251 01:42:08,100 --> 01:42:13,920 There's been a lot of, and rightfully so, there's been a lot of attention regarding food insecurity 1252 01:42:13,920 --> 01:42:15,210 amongst black persons. 1253 01:42:15,210 --> 01:42:20,470 But oftentimes when people talk about this, they think about it like, "Okay, well, this holds 1254 01:42:20,470 --> 01:42:22,800 relatively similarly across the entire country." 1255 01:42:22,800 --> 01:42:25,350 That really is not the case. 1256 01:42:25,350 --> 01:42:31,480 Is what you see here is this is look breaking this down by census regions. 1257 01:42:31,480 --> 01:42:32,480 Okay? 1258 01:42:32,480 --> 01:42:36,099 So you have the Midwest, Northeast, South, and West for each of the groups. 1259 01:42:36,099 --> 01:42:40,540 For black, non-Hispanic, Hispanic, other non-Hispanic, and white non-Hispanic. 1260 01:42:40,540 --> 01:42:43,130 And these are for metro areas. 1261 01:42:43,130 --> 01:42:49,041 So we can see is the South actually has the lowest rate of food insecurity amongst black 1262 01:42:49,041 --> 01:42:50,041 persons. 1263 01:42:50,041 --> 01:42:53,590 Of any of the census regions, what really stands out is this. 1264 01:42:53,590 --> 01:42:57,850 And the Upper Midwest is you have these food insecurity rates. 1265 01:42:57,850 --> 01:43:01,300 Which are roughly 30 percent higher than any other region in the country. 1266 01:43:01,300 --> 01:43:02,300 And why is this? 1267 01:43:02,300 --> 01:43:06,870 This is probably through long histories of segregation in the Upper Midwest. 1268 01:43:06,870 --> 01:43:12,489 Whether it be in Chicago, whether it be in Detroit, whether it be in Milwaukee or Minneapolis. 1269 01:43:12,489 --> 01:43:16,480 Across the board, you see these long manifestations of segregation. 1270 01:43:16,480 --> 01:43:23,020 Which results in really high rates of food insecurity amongst blacks in those areas. 1271 01:43:23,020 --> 01:43:27,989 So, I think this is, again, a lot of attention being paid to the food insecurity amongst 1272 01:43:27,989 --> 01:43:28,989 black persons. 1273 01:43:28,989 --> 01:43:32,200 However, much less attention has been paid to the fact that this is mainly an Upper Midwest 1274 01:43:32,200 --> 01:43:38,750 phenomenon that we need to address in thinking about this. Okay? 1275 01:43:38,750 --> 01:43:42,130 The third group is young adults not in college. 1276 01:43:42,130 --> 01:43:47,739 Now, unfortunately, is that there was all this attention paid to quote, unquote 1277 01:43:47,739 --> 01:43:55,610 this college hunger across the country and was based upon some really poor and poorly done research 1278 01:43:55,610 --> 01:43:59,260 that showed these incredibly high rates of food insecurity amongst college students. 1279 01:43:59,260 --> 01:44:03,310 Which twice that of even most of the groups that were at the most high risk. 1280 01:44:03,310 --> 01:44:09,020 And so those of us who are experts in food insecurity...who do work in the food insecurity area. 1281 01:44:09,020 --> 01:44:12,219 We thought, of course, this work isn't valid. 1282 01:44:12,219 --> 01:44:13,500 I mean, nobody took it seriously. 1283 01:44:13,500 --> 01:44:16,489 But unfortunately, some in the media took it seriously, and even worse, some policymakers 1284 01:44:16,489 --> 01:44:17,910 took it seriously. 1285 01:44:17,910 --> 01:44:19,290 So, what I did is, I said, "Okay, 1286 01:44:19,290 --> 01:44:24,050 Well, what do the food insecurity rates amongst college students really look like compared 1287 01:44:24,050 --> 01:44:25,050 to the general population?" 1288 01:44:25,050 --> 01:44:29,570 What you see here is those college students who are full-time students. 1289 01:44:29,570 --> 01:44:33,770 The vast majority of college students are full-time students have rates that are much 1290 01:44:33,770 --> 01:44:36,030 less than the general population. 1291 01:44:36,030 --> 01:44:37,719 This line here in black. Okay? 1292 01:44:37,719 --> 01:44:43,730 So if every year from 2004 to 2018 lower rates of food insecurity amongst college students. 1293 01:44:43,730 --> 01:44:48,440 The main issue, though, is that there's amongst non-college students in this red line. 1294 01:44:48,440 --> 01:44:52,380 Is non-college students between the ages of 18 and 25. 1295 01:44:52,380 --> 01:44:55,540 Their rates are double those of college students. 1296 01:44:55,540 --> 01:44:58,630 So largely this whole thing about college hunger, it's not a myth. 1297 01:44:58,630 --> 01:45:01,080 I mean, some college students are food insecure. 1298 01:45:01,080 --> 01:45:04,810 But if we want to...if we're concerned with issues of equity. 1299 01:45:04,810 --> 01:45:10,290 It's we've got a lot more concerned about non-college students than college students. 1300 01:45:10,290 --> 01:45:13,469 They have much higher rates of food insecurity than college students. 1301 01:45:13,469 --> 01:45:15,850 And their rates are higher than the general population. 1302 01:45:15,850 --> 01:45:17,889 Unlike college students, which have really low rates of food insecurity. 1303 01:45:17,889 --> 01:45:22,730 So I think we need to take away the focus from college students who aren't at much risk 1304 01:45:22,730 --> 01:45:27,630 to non-college students who are young and facing serious risks. 1305 01:45:27,630 --> 01:45:29,920 That's the third overlooked group. 1306 01:45:29,920 --> 01:45:34,480 The fourth overlooked group is 50-59-year olds, Okay? 1307 01:45:34,480 --> 01:45:39,560 Is I think we really do need to concentrate a lot on food insecurity amongst seniors in 1308 01:45:39,560 --> 01:45:40,560 our country. 1309 01:45:40,560 --> 01:45:41,560 Okay? 1310 01:45:41,560 --> 01:45:42,560 This is the blue line here. 1311 01:45:42,560 --> 01:45:45,540 This is the food insecurity rate amongst seniors. 1312 01:45:45,540 --> 01:45:50,150 And this is derived from work that my amazing co-author, James Ziliak, and I have done over 1313 01:45:50,150 --> 01:45:54,050 the years to publish food insecurity rates for seniors in our country. 1314 01:45:54,050 --> 01:45:58,230 Recently, though, in work that we've been doing for food in America is, we've been looking 1315 01:45:58,230 --> 01:46:03,409 at food insecurity rates for those between the ages of 50-59, Okay? 1316 01:46:03,409 --> 01:46:04,409 And what do we see there? 1317 01:46:04,409 --> 01:46:08,540 We see that their rates of food insecurity are really high. 1318 01:46:08,540 --> 01:46:14,840 And substantially and quite higher than those in the 60-60+ age range. 1319 01:46:14,840 --> 01:46:17,880 So I think that this is another example where we have to... 1320 01:46:17,880 --> 01:46:20,590 there hasn't been much attention being paid to the 50-59-year-olds. 1321 01:46:20,590 --> 01:46:25,950 I think we should pay more attention to them given their higher rates of food insecurity. 1322 01:46:25,950 --> 01:46:34,420 And the fact that some of the things that are...are benefits for older Americans, which 1323 01:46:34,420 --> 01:46:38,429 are fantastic, like easier to get onto SNAP, Social Security, and other things aren't as available 1324 01:46:38,429 --> 01:46:44,059 to these individuals who are right below that 60-year-old threshold. 1325 01:46:44,059 --> 01:46:46,920 So we then we see that those 50-59-year-olds group is the fourth group. 1326 01:46:46,920 --> 01:46:54,630 Now the fifth and final group is the most important group that we need to spend a lot 1327 01:46:54,630 --> 01:46:56,150 more time talking about. 1328 01:46:56,150 --> 01:46:57,150 Okay. 1329 01:46:57,150 --> 01:47:00,800 The leading cause of food insecurity in our country today is disability status. 1330 01:47:00,800 --> 01:47:03,620 Really, nothing else even comes close to this. 1331 01:47:03,620 --> 01:47:09,199 So you can't talk about food insecurity without talking about disability status. 1332 01:47:09,199 --> 01:47:15,810 And in fact, one of the speakers at this conference is Alisha Coleman-Jensen has done a lot of really 1333 01:47:15,810 --> 01:47:18,300 neat work on disability status. 1334 01:47:18,300 --> 01:47:22,389 So she's probably not talking about that, but she's done a lot of neat work on this. 1335 01:47:22,389 --> 01:47:28,500 Okay, so what we see is that those with disabilities within a household is. 1336 01:47:28,500 --> 01:47:33,080 Could be a child with a disability, could be a parent with a disability, could be a 1337 01:47:33,080 --> 01:47:34,210 senior with a disability. 1338 01:47:34,210 --> 01:47:35,340 All these different dimensions. 1339 01:47:35,340 --> 01:47:39,810 So what we see is that those with households with disabilities have much higher rates of 1340 01:47:39,810 --> 01:47:43,139 food insecurity, especially those with mental health disabilities. 1341 01:47:43,139 --> 01:47:50,440 That even has a bigger impact on food insecurity than physical health disabilities. 1342 01:47:50,440 --> 01:47:51,480 Okay? 1343 01:47:51,480 --> 01:47:56,440 So is that what you could see here is that we're looking at the four groups I talked 1344 01:47:56,440 --> 01:47:57,440 about before. 1345 01:47:57,440 --> 01:48:02,870 This is broken down by percentage of persons, the food insecurity rate for those with disabilities 1346 01:48:02,870 --> 01:48:04,530 among American Indians. 1347 01:48:04,530 --> 01:48:10,030 So, you know, it's roughly you know, 14 percentage points higher. 1348 01:48:10,030 --> 01:48:12,800 Look at this, though, for 50-59 across the board, 1349 01:48:12,800 --> 01:48:14,160 non-college students, okay? 1350 01:48:14,160 --> 01:48:19,590 It's over twice as high for those with a disability than those without a disability. 1351 01:48:19,590 --> 01:48:22,521 Or looking at 50-59-year-olds look. 1352 01:48:22,521 --> 01:48:29,530 It's almost what's going on (INAUDIBLE) about four times higher for 50-59-year-olds with 1353 01:48:29,530 --> 01:48:31,860 a disability compared to those without a disability. 1354 01:48:31,860 --> 01:48:33,369 So we have to talk. 1355 01:48:33,369 --> 01:48:37,699 We can't really have a conversation about food insecurity in our country without talking 1356 01:48:37,699 --> 01:48:38,699 about disability. 1357 01:48:38,699 --> 01:48:44,290 So I want to say is that these five overlooked groups American Indians, black persons in 1358 01:48:44,290 --> 01:48:51,590 the Upper Midwest, Non-college students, 50-59-year-olds, and most critically, those with disabilities. 1359 01:48:51,590 --> 01:48:57,100 I encourage more research in this area and more ways to figure out policies to address this. 1360 01:48:57,100 --> 01:48:58,159 Okay? 1361 01:48:58,159 --> 01:49:06,040 So. Now, the good news is that it's straightforward and easy to end food insecurity in the United States. 1362 01:49:06,040 --> 01:49:11,590 This is not a difficult challenge to figure out how to end food insecurity in the United States. 1363 01:49:11,590 --> 01:49:14,659 So what I want to do is put forth, you know why it's so easy to end this. 1364 01:49:14,659 --> 01:49:15,659 Okay? 1365 01:49:15,659 --> 01:49:18,199 We have this amazing program in our country called SNAP. 1366 01:49:18,199 --> 01:49:21,070 Everybody in the audience is aware of SNAP. 1367 01:49:21,070 --> 01:49:27,680 And the advantage to SNAP is that it meets its central goal of reducing food insecurity. 1368 01:49:27,680 --> 01:49:32,560 Study after study after study has shown that SNAP leads to reductions in food insecurity. 1369 01:49:32,560 --> 01:49:34,200 This has become a stylized fact. 1370 01:49:34,200 --> 01:49:39,380 Now, the main reason it does this, there are several reasons why it does. 1371 01:49:39,380 --> 01:49:40,980 But I want to concentrate on one. 1372 01:49:40,980 --> 01:49:43,489 It gives dignity and autonomy to recipients. 1373 01:49:43,489 --> 01:49:44,489 Okay? 1374 01:49:44,489 --> 01:49:48,739 So many of the assistance programs in our country are demeaning or patronizing. 1375 01:49:48,739 --> 01:49:54,020 Including some food assistance programs towards those who are vulnerable. 1376 01:49:54,020 --> 01:49:56,540 SNAP doesn't do this. 1377 01:49:56,540 --> 01:50:01,739 SNAP says to recipients we trust you to make the right decisions with these benefits. 1378 01:50:01,739 --> 01:50:04,949 You can go to a store and shop alongside your neighbors and friends. 1379 01:50:04,949 --> 01:50:09,560 And the same way that they're shopping, make the same type of decisions that they're doing. 1380 01:50:09,560 --> 01:50:15,320 In other words, it assures—and this is some other work that I’ve done—it assures…SNAP helps us assure this right to food 1381 01:50:15,320 --> 01:50:21,650 in our country by giving people dignity and autonomy 1382 01:50:21,650 --> 01:50:23,700 to make their own choices. 1383 01:50:23,700 --> 01:50:27,199 This is critical to SNAP being a successful program, 1384 01:50:27,199 --> 01:50:29,570 unlike some other programs. 1385 01:50:29,570 --> 01:50:35,830 So any discussion about SNAP...I'm sorry, about food insecurity and alleviate it has to begin 1386 01:50:35,830 --> 01:50:36,830 and end with SNAP. 1387 01:50:36,830 --> 01:50:39,060 There's no more important program. 1388 01:50:39,060 --> 01:50:44,710 So in a recent paper that I wrote in Food Policy is... 1389 01:50:44,710 --> 01:50:51,670 it looks at the issue is reconstructing SNAP as a universal basic income program. 1390 01:50:51,670 --> 01:50:57,520 And the way that this is structured is that every household would get the SNAP maximum 1391 01:50:57,520 --> 01:50:58,520 benefit level. 1392 01:50:58,520 --> 01:51:01,030 Okay, so this is the way it's structured is you know. 1393 01:51:01,030 --> 01:51:06,580 No phase-out with as incomes increases, every American would get the maximum SNAP benefit 1394 01:51:06,580 --> 01:51:07,880 level, okay? 1395 01:51:07,880 --> 01:51:12,270 And this would then be paid with taxes based upon the current distribution of income taxation. 1396 01:51:12,270 --> 01:51:18,030 For example, 70 percent of all taxes are paid well by most of us who are at this conference. 1397 01:51:18,030 --> 01:51:25,371 And that up to 10 percent of income in our country and over 97 percent is paid by those in the top half. 1398 01:51:25,371 --> 01:51:30,460 So in other words is this by paying for this expansion of SNAP is to be paid by those who 1399 01:51:30,460 --> 01:51:34,740 are already paying the vast majority of taxes in our country. 1400 01:51:34,740 --> 01:51:39,349 I first consider those paper SNAP as UBI but then I consider a modification. 1401 01:51:39,349 --> 01:51:44,639 The first is that probably people like myself really do not need SNAP, of course. 1402 01:51:44,639 --> 01:51:51,605 And so, therefore, as I said, Okay, well, suppose we cut off this with incomes up to 400 percent of the poverty line. 1403 01:51:51,605 --> 01:51:53,865 Okay? Roughly $100,000 for a family of four. 1404 01:51:53,865 --> 01:51:57,880 And so we say, OK, those above that income threshold will have to pay taxes to help support 1405 01:51:57,880 --> 01:52:00,010 this but they won't get the SNAP benefit. 1406 01:52:00,010 --> 01:52:03,690 The other thing is to increase benefits by $42 per week. 1407 01:52:03,690 --> 01:52:07,639 This $42 per week comes out of a study that two of my other amazing co-authors 1408 01:52:07,639 --> 01:52:12,800 John Pepper and Brent Kreider and I wrote basically showing that if you increase SNAP 1409 01:52:12,800 --> 01:52:15,040 benefits by about 25 percent. 1410 01:52:15,040 --> 01:52:20,349 Is that this would allow there to be a reduction in food insecurity amongst SNAP recipients 1411 01:52:20,349 --> 01:52:21,730 of about 60 percent. 1412 01:52:21,730 --> 01:52:26,969 And the good news is the USDA recently put in this large increase in SNAP benefits: 1413 01:52:26,969 --> 01:52:29,870 Maximum SNAP benefits between 20 to 25 percent. 1414 01:52:29,870 --> 01:52:32,790 It wasn't because of Brent, John, and mine's work. 1415 01:52:32,790 --> 01:52:35,460 But it is almost identical to what we are proposing. 1416 01:52:35,460 --> 01:52:41,310 By the way, for those of you interested, one of my other amazing coauthors is Elaine Waxman. 1417 01:52:41,310 --> 01:52:45,110 You're going to get to hear from her throughout this conference. 1418 01:52:45,110 --> 01:52:52,199 She and I have done some work looking at this topic along with Olivia Friel to see what 1419 01:52:52,199 --> 01:52:57,119 happens once benefit levels are increased and the profound impact that has on making 1420 01:52:57,119 --> 01:52:59,540 sure more Americans can afford enough food. 1421 01:52:59,540 --> 01:53:01,210 Okay, so that's just an aside. 1422 01:53:01,210 --> 01:53:08,563 However, is if I put both these modifications into this is that the impacts are profound. 1423 01:53:08,563 --> 01:53:15,210 There will be a 98.2 percent decline in food insecurity in the United States. Essentially food insecurity will be eliminated if we put this into place. 1424 01:53:15,210 --> 01:53:19,730 Okay? The cost of this would be roughly half a trillion dollars, okay? 1425 01:53:19,730 --> 01:53:21,760 You might say, "Oh, that's a lot of money." 1426 01:53:21,760 --> 01:53:23,280 Well, yes, it is. 1427 01:53:23,280 --> 01:53:29,409 But it's far less than what the combined stimulus packages from the Biden administration and 1428 01:53:29,409 --> 01:53:30,660 Trump administration had. 1429 01:53:30,660 --> 01:53:33,239 So in that sense, it's really not that expensive. 1430 01:53:33,239 --> 01:53:34,900 I pointed this out. 1431 01:53:34,900 --> 01:53:40,860 It's well to show that, look, this is we can eliminate food insecurity in the United States. 1432 01:53:40,860 --> 01:53:43,099 It's not hard to eliminate food insecurity. 1433 01:53:43,099 --> 01:53:46,300 It's not cheap to do so, but we definitely could do so. 1434 01:53:46,300 --> 01:53:48,830 And even if this program like this is not implemented. 1435 01:53:48,830 --> 01:53:54,150 At least it gives us a guide to be able to say, okay. 1436 01:53:54,150 --> 01:54:01,150 This is what we can do to end food insecurity in the United States. And no one should ever say. "Oh, this problem can't be eliminated." 1437 01:54:01,150 --> 01:54:08,540 Okay? So again, SNAP is an amazing program. Let's make it even more amazing in our country to completely eliminate food insecurity. 1438 01:54:08,540 --> 01:54:13,940 And in particular to eliminate food insecurity amongst these overlooked groups that I've 1439 01:54:13,940 --> 01:54:16,010 talked about in this presentation. 1440 01:54:16,010 --> 01:54:21,372 Thank you very much. Enjoy the rest of the conference. 1441 01:54:21,372 --> 01:54:27,100 DR. VALERIE BLUE BIRD JERNIGAN: Hello, I am Valerie Blue Bird Jernigan. 1442 01:54:27,100 --> 01:54:30,920 I am a professor of rural health at Oklahoma State University, where I direct the Center 1443 01:54:30,920 --> 01:54:34,010 for Indigenous Health Research and Policy. 1444 01:54:34,010 --> 01:54:45,270 And I'll be speaking with you today about food insecurity among Native American communities. 1445 01:54:45,270 --> 01:54:52,389 I want to share a bit about the historic roots of food insecurity among Native Americans. 1446 01:54:52,389 --> 01:55:03,050 Shown here you see a photograph taken of a ration ticket issued in the mid-1880s 1447 01:55:03,050 --> 01:55:08,400 to a member of the Oglala Lakota tribe on the Pine Ridge Reservation in the southwest 1448 01:55:08,400 --> 01:55:11,719 corner of what is today South Dakota. 1449 01:55:11,719 --> 01:55:19,270 The number nine here indicates this person was allowed to draw rations of beef. 1450 01:55:19,270 --> 01:55:28,880 And also when available beans, corn flour, salt and occasionally sugar, coffee, soap, 1451 01:55:28,880 --> 01:55:37,909 and tobacco for nine dependents each Saturday. 1452 01:55:37,909 --> 01:55:45,989 These rations were provided to Native people because their traditional foods buffalo specifically 1453 01:55:45,989 --> 01:55:49,260 in this Tribe had been decimated. 1454 01:55:49,260 --> 01:55:57,490 And these rations were provided to them to prevent them from starvation. 1455 01:55:57,490 --> 01:56:01,520 So the roots of food insecurity among Native people are deep. 1456 01:56:01,520 --> 01:56:10,640 And when we study food insecurity among Natives, we cannot separate out that history of displacement 1457 01:56:10,640 --> 01:56:18,099 and removal from traditional food systems to restricted reservations which altered our 1458 01:56:18,099 --> 01:56:27,060 dietary patterns and had repercussions for our modern food systems and environments. 1459 01:56:27,060 --> 01:56:39,480 I'm providing an overview of existing knowledge on this topic, and there has been relatively 1460 01:56:39,480 --> 01:56:44,230 limited research conducted on food insecurity and Natives. 1461 01:56:44,230 --> 01:56:48,510 Most studies rely on small or regional samples. 1462 01:56:48,510 --> 01:56:56,210 In 2013, my colleagues and I looked at California Health Interview Survey data. 1463 01:56:56,210 --> 01:57:07,460 And we found that 38.7 percent of natives with incomes below 200 percent of the federal poverty level were food insecure. 1464 01:57:07,460 --> 01:57:17,570 Another study of a reservation sample in Montana found 43 percent of households surveyed were food insecure. 1465 01:57:17,570 --> 01:57:25,300 And in our recent Thrive Intervention study in rural Oklahoma, we found 60 percent of Natives 1466 01:57:25,300 --> 01:57:27,310 were food insecure. 1467 01:57:27,310 --> 01:57:34,690 We also found that the prevalence of obesity and diabetes and hypertension was higher among 1468 01:57:34,690 --> 01:57:40,840 those who were food insecure compared to those who were food secure, even after adjustment 1469 01:57:40,840 --> 01:57:52,320 for age, gender, study site, education, and income. 1470 01:57:52,320 --> 01:58:00,710 We also looked at the current population surveys, food security supplement data. 1471 01:58:00,710 --> 01:58:08,119 And we analyzed food insecurity trends among Natives compared to other racial and ethnic 1472 01:58:08,119 --> 01:58:12,650 groups in the U.S. from 2000 to 2010. 1473 01:58:12,650 --> 01:58:20,400 We found that 25 percent of natives remained consistently food insecure during that time period. 1474 01:58:20,400 --> 01:58:26,080 Natives were twice as likely to be food insecure when compared to whites. 1475 01:58:26,080 --> 01:58:33,000 And in this sample, urban Natives were also more likely to experience food insecurity 1476 01:58:33,000 --> 01:58:38,599 then rural Natives. 1477 01:58:38,599 --> 01:58:43,400 My colleagues and I recently formed a small group we call ICHANGES. 1478 01:58:43,400 --> 01:58:53,060 And this stands for Indigenous Collaborative for Health Agriculture Nutrition Growers and 1479 01:58:53,060 --> 01:58:55,869 Environmental Sovereignty. 1480 01:58:55,869 --> 01:59:03,730 This group was developed to better understand food insecurity and ways to address it among 1481 01:59:03,730 --> 01:59:06,250 Native communities. 1482 01:59:06,250 --> 01:59:10,350 We conducted a scoping review this year. 1483 01:59:10,350 --> 01:59:16,900 We looked at food insecurity among Natives and how it relates to other socioeconomic 1484 01:59:16,900 --> 01:59:20,449 factors and nutrition and health. 1485 01:59:20,449 --> 01:59:29,870 And this particular work was led by Dr. Cassandra Nikolaus at Washington State University. 1486 01:59:29,870 --> 01:59:36,429 For the scoping review, we conducted a systematic review using PubMed. 1487 01:59:36,429 --> 01:59:41,030 Three investigators independently screened the results. 1488 01:59:41,030 --> 01:59:50,060 And each study that included quantitative food insecurity data was assessed for quality 1489 01:59:50,060 --> 01:59:53,620 by two independent members of the research team. 1490 01:59:53,620 --> 02:00:02,239 We used six criteria to assess quality based on the Methods Guide for Effectiveness and 1491 02:00:02,239 --> 02:00:04,130 Comparative Effectiveness Reviews. 1492 02:00:04,130 --> 02:00:12,880 We found a total of 34 reports that described 30 studies that were included in our final 1493 02:00:12,880 --> 02:00:14,670 narrative synthesis. 1494 02:00:14,670 --> 02:00:21,140 Most of the studies 73 percent were cross-sectional. 1495 02:00:21,140 --> 02:00:30,580 The weighted average prevalence of food insecurity was 45.7 percent though estimates varied from 16 1496 02:00:30,580 --> 02:00:39,420 to 80 percent. 1497 02:00:39,420 --> 02:00:48,300 Food insecure households had higher intake of sugar-sweetened beverages and fried foods 1498 02:00:48,300 --> 02:00:49,570 among children and adults. 1499 02:00:49,570 --> 02:00:56,400 They had poorer nutritional health and risk. 1500 02:00:56,400 --> 02:01:00,920 Transportation barriers were common in food-insecure households. 1501 02:01:00,920 --> 02:01:10,210 They had long distances to food retailers, and they consumed low amounts of fruits and 1502 02:01:10,210 --> 02:01:12,940 vegetables. 1503 02:01:12,940 --> 02:01:20,679 Studies identified food preservation and gardening across familial generations as a key opportunity 1504 02:01:20,679 --> 02:01:29,020 to not only ensure food security but also to provide financial income. 1505 02:01:29,020 --> 02:01:36,099 And acknowledging the meaning and value of traditional foods and their role in promoting 1506 02:01:36,099 --> 02:01:37,099 food security. 1507 02:01:37,099 --> 02:01:44,010 And food sovereignty was something that several of the studies cited as being important to 1508 02:01:44,010 --> 02:01:46,270 Native communities. 1509 02:01:46,270 --> 02:01:54,579 There was also more research being called to capture and address the unique characteristics 1510 02:01:54,579 --> 02:01:58,480 between rural and urban Native communities. 1511 02:01:58,480 --> 02:02:06,670 About 70 percent at this point of Native people live in urban areas. 1512 02:02:06,670 --> 02:02:15,610 And so we need to know a lot more about urban Native communities and food security in those 1513 02:02:15,610 --> 02:02:16,610 areas. 1514 02:02:16,610 --> 02:02:20,400 I'll transition here to solutions. 1515 02:02:20,400 --> 02:02:29,329 As an interventionist, my work focuses primarily on research that seeks to reduce and eliminate 1516 02:02:29,329 --> 02:02:31,350 food insecurity. 1517 02:02:31,350 --> 02:02:37,250 To address food insecurity in Native communities we're focusing on food sovereignty. 1518 02:02:37,250 --> 02:02:41,940 Which I've defined here using one of the more common definitions. 1519 02:02:41,940 --> 02:02:47,070 And it's really the right and for Native peoples. 1520 02:02:47,070 --> 02:02:53,590 The responsibility of Native people to healthy and culturally appropriate foods. 1521 02:02:53,590 --> 02:03:01,870 So it's a food system in which the people, in other words, the people who produce, distribute 1522 02:03:01,870 --> 02:03:09,599 and consume food, also control the mechanisms and policies of food production and distribution. 1523 02:03:09,599 --> 02:03:16,170 This is opposed to what we currently have the corporate food regime, 1524 02:03:16,170 --> 02:03:22,360 where corporations and market institutions control the global food system. 1525 02:03:22,360 --> 02:03:29,810 Native food sovereignty adds not just the right, but also, as I said, the responsibility. 1526 02:03:29,810 --> 02:03:34,660 Because in Indigenous cultures food is considered a sacred gift. 1527 02:03:34,660 --> 02:03:42,520 And we have responsibilities to take care of the land and water and ecosystem that produces 1528 02:03:42,520 --> 02:03:44,010 those gifts. 1529 02:03:44,010 --> 02:03:49,870 A primary difference between food security and food sovereignty is that. 1530 02:03:49,870 --> 02:03:56,300 Food sovereignty focuses on restoring the connection Indigenous people have with their 1531 02:03:56,300 --> 02:03:58,179 food systems and land. 1532 02:03:58,179 --> 02:04:03,960 And not just the provision of food to poor communities. 1533 02:04:03,960 --> 02:04:13,500 The food sovereignty approach emphasizes source and connectedness and sustainability. 1534 02:04:13,500 --> 02:04:19,250 And therefore interventions that are guided by a food sovereignty model are much more 1535 02:04:19,250 --> 02:04:25,880 likely to facilitate long-term systems change. 1536 02:04:25,880 --> 02:04:35,070 I included this model from the Council of Canadian Academies because I really like it. 1537 02:04:35,070 --> 02:04:39,900 It highlights the dynamic relationship between food security and food sovereignty and the 1538 02:04:39,900 --> 02:04:45,780 factors that influence both of these concepts in Native communities. 1539 02:04:45,780 --> 02:04:56,060 As we see food security is connected to colonization and environmental change and the economic 1540 02:04:56,060 --> 02:04:57,679 well-being of communities. 1541 02:04:57,679 --> 02:05:06,380 And those factors have to be considered when we are intervening on food insecurity and 1542 02:05:06,380 --> 02:05:11,040 all of the associated health outcomes. 1543 02:05:11,040 --> 02:05:22,679 Food sovereignty as this model depicts can be thought of as a way to facilitate food 1544 02:05:22,679 --> 02:05:25,710 security. 1545 02:05:25,710 --> 02:05:33,520 And this is my last slide, I just want to emphasize we are actively implementing food sovereignty 1546 02:05:33,520 --> 02:05:36,270 interventions in Native communities. 1547 02:05:36,270 --> 02:05:42,900 We are intervening, my research group and others, multiple levels of the food system, 1548 02:05:42,900 --> 02:05:48,719 to create long-term healthy food access and food security. 1549 02:05:48,719 --> 02:05:53,179 I've included a couple of pictures here from several of our studies. 1550 02:05:53,179 --> 02:06:00,059 Our THRIVE study intervened and it just ended this past year. 1551 02:06:00,059 --> 02:06:07,400 THRIVE intervened to create healthy makeovers in Tribally owned and operated convenience 1552 02:06:07,400 --> 02:06:08,400 stores. 1553 02:06:08,400 --> 02:06:13,460 And this was in the Chickasaw and Choctaw Nations of Oklahoma. 1554 02:06:13,460 --> 02:06:24,000 And it increased healthy food purchasing and access and had no risk on the bottom line 1555 02:06:24,000 --> 02:06:25,880 of these convenience stores. 1556 02:06:25,880 --> 02:06:31,400 It actually increased the revenue of the stores. 1557 02:06:31,400 --> 02:06:38,770 We are currently implementing the FRESH study with Osage Nation, a farm-to-school intervention, 1558 02:06:38,770 --> 02:06:42,590 which supplies nine Tribal Head Starts. 1559 02:06:42,590 --> 02:06:51,260 And the families whose children attend those Head Starts with produce from a Tribal farm 1560 02:06:51,260 --> 02:06:55,440 that was developed in tandem with this study. 1561 02:06:55,440 --> 02:07:02,760 And most recently, a community-supported agriculture study also with Osage Nation. 1562 02:07:02,760 --> 02:07:11,489 That expands the farm-to-school intervention to a community-wide study of this community-supported 1563 02:07:11,489 --> 02:07:15,050 agriculture initiative and its impact. 1564 02:07:15,050 --> 02:07:23,290 We're going to study its impact on food security, BMI, hypertension, and A1c levels. 1565 02:07:23,290 --> 02:07:25,530 So it can be done. 1566 02:07:25,530 --> 02:07:29,199 And we're seeing really exciting changes. 1567 02:07:29,199 --> 02:07:36,760 Our work was also featured in the Blood Sugar Rising documentary that was recently released 1568 02:07:36,760 --> 02:07:37,760 by PBS. 1569 02:07:37,760 --> 02:07:42,260 That's why I have this picture up here, Blood Sugar Rising. 1570 02:07:42,260 --> 02:07:47,590 So check that out, and I'm now happy to take your questions. 1571 02:07:47,590 --> 02:07:48,590 Thank you. 1572 02:07:48,590 --> 02:07:56,679 DR. LORRENE RITCHIE: Good afternoon, I'm Lorrene Ritchie, the director of the Nutrition Policy 1573 02:07:56,679 --> 02:08:01,230 Institute at the University of California's Division of Agriculture and Natural Resources. 1574 02:08:01,230 --> 02:08:06,270 At NPI, we conduct Public Health Nutrition Research to inform programs and policies to 1575 02:08:06,270 --> 02:08:08,719 improve food insecurity among children and families. 1576 02:08:08,719 --> 02:08:13,500 And I'm going to be talking today about factors associated with food insecurity across the 1577 02:08:13,500 --> 02:08:14,500 lifespan. 1578 02:08:14,500 --> 02:08:20,290 Because my own research focuses on children, to prepare for this talk, I turn 1579 02:08:20,290 --> 02:08:25,389 to the published literature, and I started with Craig Gundersen and James Ziliak's 2015 1580 02:08:25,389 --> 02:08:29,940 review article on Health Affairs, which summarized research on the impacts of food insecurity 1581 02:08:29,940 --> 02:08:32,500 published since 2001. 1582 02:08:32,500 --> 02:08:37,770 As you can see from this slide from a basic PubMed search, publications on food insecurity 1583 02:08:37,770 --> 02:08:40,960 in the U.S. have increased dramatically since 2015. 1584 02:08:40,960 --> 02:08:46,040 So, what I will summarize is my take on the evidence building upon Craig's excellent review 1585 02:08:46,040 --> 02:08:49,270 by adding findings from more recent reviews and studies. 1586 02:08:49,270 --> 02:08:54,520 Please note, though, it is not a comprehensive, systematic review or meta-analysis, but more 1587 02:08:54,520 --> 02:08:55,520 of a scoping review. 1588 02:08:55,520 --> 02:08:59,350 So, please forgive me if you don't see any of your studies or others you know about cited 1589 02:08:59,350 --> 02:09:00,350 here. 1590 02:09:00,350 --> 02:09:06,010 In the next few slides, I'll summarize where evidence exists, as well as where I see gaps 1591 02:09:06,010 --> 02:09:11,960 and opportunities with respect to impacts of food insecurity across the lifespan. 1592 02:09:11,960 --> 02:09:16,880 As Craig highlighted earlier in this session, disparities in food insecurity exists across 1593 02:09:16,880 --> 02:09:17,880 the lifespan. 1594 02:09:17,880 --> 02:09:22,600 In addition to the most obvious risk factor poverty, higher prevalence of food insecurity 1595 02:09:22,600 --> 02:09:28,969 is associated with lower educational attainment being a racial or ethnic minority, housing 1596 02:09:28,969 --> 02:09:35,380 instability, households with children, especially when run by single parents, women, younger 1597 02:09:35,380 --> 02:09:37,619 adults, and seniors living alone. 1598 02:09:37,619 --> 02:09:43,989 These are all populations with high risk of food insecurity, as are those listed on the 1599 02:09:43,989 --> 02:09:45,500 right-hand side of this slide. 1600 02:09:45,500 --> 02:09:52,190 Next, let's turn our attention to the evidence on the impacts of food insecurity from surveys 1601 02:09:52,190 --> 02:09:57,520 that, for the most part, control for those risk factors I just named, and we're going to 1602 02:09:57,520 --> 02:09:59,910 start with pregnant and breastfeeding women and infants. 1603 02:09:59,910 --> 02:10:05,890 And as you can see from the factors listed on the left of this slide, there's considerable 1604 02:10:05,890 --> 02:10:11,179 evidence to support an association between food insecurity and higher pre-pregnancy weight 1605 02:10:11,179 --> 02:10:18,139 and obesity, excess or inadequate gestational weight gain, fewer prenatal health care visits, 1606 02:10:18,139 --> 02:10:24,349 pregnancy complications, and health, mental health issues, smoking exposure. 1607 02:10:24,349 --> 02:10:30,730 And in terms of infants, premature births, birth defects, developmental delays presenting 1608 02:10:30,730 --> 02:10:38,330 to the emergency room, less immunizations and lower breastfeeding duration. 1609 02:10:38,330 --> 02:10:43,639 Topics, I think represent gaps and opportunities for further research on this life stage are 1610 02:10:43,639 --> 02:10:44,909 shown on the right. 1611 02:10:44,909 --> 02:10:48,909 And interestingly, while it is well-established for individuals and other life stages, as 1612 02:10:48,909 --> 02:10:54,159 you're going to see that food insecurity is related to the consumption of poor diet quality, typically 1613 02:10:54,159 --> 02:10:58,830 characterized by more low-cost, higher energy-dense foods. 1614 02:10:58,830 --> 02:11:03,369 During pregnancy, lactation, and in infants, the evidence associated in food insecurity 1615 02:11:03,369 --> 02:11:06,040 and diet quality is just not as consistent. 1616 02:11:06,040 --> 02:11:10,840 Other gaps in knowledge include the relationship between food insecurity and breastfeeding. 1617 02:11:10,840 --> 02:11:16,290 There's some lack of consistency with respect to breastfeeding, with some studies showing 1618 02:11:16,290 --> 02:11:18,659 impacts on duration, but not initiation. 1619 02:11:18,659 --> 02:11:25,110 Subsequent pregnancy and barriers to contraception is also a gap. 1620 02:11:25,110 --> 02:11:29,929 A recurring theme you're going to notice across the life stages is the need to better understand 1621 02:11:29,929 --> 02:11:35,579 longer-term impacts, and whether there are critical stages in a lifespan where those 1622 02:11:35,579 --> 02:11:44,079 longer-term impacts are more profound or detrimental, also applies to infants and during pregnancy 1623 02:11:44,079 --> 02:11:45,849 and lactation. 1624 02:11:45,849 --> 02:11:51,640 Gaps on birth weight and infant adiposity impacts and weight status later in life and 1625 02:11:51,640 --> 02:11:52,840 later child development. 1626 02:11:52,840 --> 02:11:57,710 And then finally, an emerging area of research has to do with whether parents and other caregivers 1627 02:11:57,710 --> 02:12:02,770 change how they feed infants and older children as well in the context of food insecurity. 1628 02:12:02,770 --> 02:12:05,920 And interestingly, the evidence is building that there may be a connection. 1629 02:12:05,920 --> 02:12:11,480 For example, Grosz and colleagues in 2018 in a sample of low-income Hispanic households 1630 02:12:11,480 --> 02:12:15,469 found that prolonged food insecurity during both pregnancy and postpartum was associated 1631 02:12:15,469 --> 02:12:20,989 with greater maternal pressuring of infants to eat. 1632 02:12:20,989 --> 02:12:27,040 Swindell, in a 2020 study, found that preschool and early care and education teachers that 1633 02:12:27,040 --> 02:12:32,690 were food insecure were more likely to use authoritarian feeding styles, another feeding 1634 02:12:32,690 --> 02:12:34,630 practice that is associated with child obesity. 1635 02:12:34,630 --> 02:12:37,090 So, an interesting area for further research. 1636 02:12:37,090 --> 02:12:44,580 For children and adolescents, there's evidence that food insecurity is associated with multiple 1637 02:12:44,580 --> 02:12:45,580 impacts. 1638 02:12:45,580 --> 02:12:51,559 Diet quality, nutrient intake, and iron deficiency anemia are impacts shown in the research. 1639 02:12:51,559 --> 02:12:57,960 Asthma, high blood pressure, dental problems, hospital visits, early menarche, and obesity 1640 02:12:57,960 --> 02:13:00,590 especially in older children and girls. 1641 02:13:00,590 --> 02:13:06,559 Regarding obesity, there are some newer studies suggesting some possible mechanisms besides 1642 02:13:06,559 --> 02:13:09,599 parent feeding practices, which I mentioned earlier. 1643 02:13:09,599 --> 02:13:14,690 For example, Delvecchio in a 2020 study found that parents in food-insecure households were 1644 02:13:14,690 --> 02:13:21,960 more likely to identify their child as underweight, even though they were normal weight than parents 1645 02:13:21,960 --> 02:13:24,460 in food secure households. 1646 02:13:24,460 --> 02:13:30,099 West and colleagues in a 2021study found food insecurity moderated the positive association 1647 02:13:30,099 --> 02:13:37,250 between low income and loss of control of eating among adolescents. 1648 02:13:37,250 --> 02:13:44,780 Unhealthy weight control practices and body image, sleep quality, parental report of poor 1649 02:13:44,780 --> 02:13:50,679 health and developmental delays, these are additional impacts well supported by the literature. 1650 02:13:50,679 --> 02:13:56,449 Moving on to suspension and expulsion in school on behaviors, absenteeism, academic performance 1651 02:13:56,449 --> 02:14:02,350 and mental health problems and even risky behaviors have been shown to be associated 1652 02:14:02,350 --> 02:14:06,000 with food insecurity among adolescents, such as failing to get money for food. 1653 02:14:06,000 --> 02:14:11,739 In terms of gaps, we need more longitudinal studies on the long-term impacts and whether 1654 02:14:11,739 --> 02:14:12,840 these differ by child age. 1655 02:14:12,840 --> 02:14:19,150 A case in point in a longitudinal study published in 2020, Xu and colleagues found that food 1656 02:14:19,150 --> 02:14:25,040 insecurity in the third, fifth, and eighth grades was associated with obesity concurrently 1657 02:14:25,040 --> 02:14:26,150 or in later grades. 1658 02:14:26,150 --> 02:14:31,179 But food insecurity in kindergarten was associated with underweight. 1659 02:14:31,179 --> 02:14:37,369 In another study published in 2020 by Gomber and colleagues, they found that food insecurity 1660 02:14:37,369 --> 02:14:43,440 in early life was associated with lower BMI in ages 2 to 3.5 years, but increased BMI 1661 02:14:43,440 --> 02:14:45,800 3.5 and older. 1662 02:14:45,800 --> 02:14:53,730 Again, suggesting potential differential impacts of food insecurity over time. 1663 02:14:53,730 --> 02:14:55,369 Gender differences are not always observed. 1664 02:14:55,369 --> 02:14:59,650 But when they are, as I pointed out, food insecurity tends to have greater impacts in 1665 02:14:59,650 --> 02:15:02,219 girls and women compared to boys and men. 1666 02:15:02,219 --> 02:15:09,030 But how these differences relate to gender norms versus biology merits additional study. 1667 02:15:09,030 --> 02:15:14,540 Eating disorders, you know, not all studies have shown a consistent relationship between 1668 02:15:14,540 --> 02:15:16,290 food insecurity and disordered eating. 1669 02:15:16,290 --> 02:15:21,980 A recent study by Eagleton in 2021, for example, found that household food insecurity was associated 1670 02:15:21,980 --> 02:15:27,190 with higher food responsiveness in children as young as 3 to 5 years old, but only 1671 02:15:27,190 --> 02:15:32,670 when parents reported high levels of stress and low levels of family functioning, which 1672 02:15:32,670 --> 02:15:35,150 leads to our next gap. 1673 02:15:35,150 --> 02:15:38,400 And that is how other adversity relates to food insecurity. 1674 02:15:38,400 --> 02:15:44,670 Most studies aren't able to capture the details on all the elements of a person's family or 1675 02:15:44,670 --> 02:15:48,500 community context or social capital, and how this influences their experience and impacts 1676 02:15:48,500 --> 02:15:49,650 their food insecurity. 1677 02:15:49,650 --> 02:15:56,520 Interestingly, also, most of the existing literature is deficit focused, measuring what 1678 02:15:56,520 --> 02:16:02,670 factors increase food insecurity, but not what protects children from food insecurity. 1679 02:16:02,670 --> 02:16:07,420 And finally, there's a need to identify an optimal food insecurity measure for children. 1680 02:16:07,420 --> 02:16:13,710 Most study to date of child impacts, based food insecurity on parent report and parents 1681 02:16:13,710 --> 02:16:18,250 tend estimate their children's food insecurity experience. 1682 02:16:18,250 --> 02:16:23,710 Fewer studies have used the USDA's module for ages 12 and up. 1683 02:16:23,710 --> 02:16:28,150 Freeman Frangela in 2013 did some excellent qualitative work with children to develop 1684 02:16:28,150 --> 02:16:34,240 the Child Food Security Assessment tool that can be used with children as young as eight 1685 02:16:34,240 --> 02:16:42,010 or 9 years old, and assesses not only the cognitive and emotional physical awareness 1686 02:16:42,010 --> 02:16:45,809 of food insecurity, but some actions children might take. 1687 02:16:45,809 --> 02:16:50,679 This and other child focused assessments merit further use and investigation in relationship 1688 02:16:50,679 --> 02:16:52,280 to child impacts. 1689 02:16:52,280 --> 02:16:57,809 Associations have also been examined among young adults, with most studies focusing on 1690 02:16:57,809 --> 02:16:59,630 college-aged students. 1691 02:16:59,630 --> 02:17:05,100 Again, we see impacts of food insecurity and diet quality, cooking skills, disordered eating 1692 02:17:05,100 --> 02:17:11,470 and eating disorders, academic performance, mental health, social isolation, physical 1693 02:17:11,470 --> 02:17:20,439 health and chronic disease, smoking, substance use, sexual risk, sleep and obesity and specific 1694 02:17:20,439 --> 02:17:27,010 to students financial health, such as accruing student loans and debt. 1695 02:17:27,010 --> 02:17:34,059 In terms of gaps in knowledge and this applies, really, to all stages of life. 1696 02:17:34,059 --> 02:17:35,490 Physical activity is not. 1697 02:17:35,490 --> 02:17:39,859 There are some studies that have shown association, others that have not. 1698 02:17:39,859 --> 02:17:47,599 And again, long term impacts on diet, weight and health and economic well-being. 1699 02:17:47,599 --> 02:17:51,819 For other adults where there appears to be the largest increase in studies, we see most 1700 02:17:51,819 --> 02:17:53,940 of the same impacts as for younger adults. 1701 02:17:53,940 --> 02:17:59,760 However, we're now seeing greater impacts on morbidity from diabetes, cardiovascular 1702 02:17:59,760 --> 02:18:04,380 disease, end stage renal disease, chronic obstructive pulmonary disorder and cancer, 1703 02:18:04,380 --> 02:18:08,439 as well as early death, including from intentional injury and suicide. 1704 02:18:08,439 --> 02:18:14,190 In terms of gaps, some new insights have emerged in recent years that merit additional research. 1705 02:18:14,190 --> 02:18:20,050 For example, Nettle, in a 2019 study using NHANES data, found food insecure women had 1706 02:18:20,050 --> 02:18:26,750 less varied amounts of food and more variations in when they ate. 1707 02:18:26,750 --> 02:18:34,179 Factors which in other studies have been associated with potential risk of obesity. 1708 02:18:34,179 --> 02:18:38,670 Work performance is a gap in our knowledge. 1709 02:18:38,670 --> 02:18:40,360 And physical activity again, and racism. 1710 02:18:40,360 --> 02:18:45,399 A 2019 study in Philadelphia found that among Latinx and black mothers, their experiences 1711 02:18:45,399 --> 02:18:49,670 of discrimination in schools, a child or in the workplace as an adult were associated 1712 02:18:49,670 --> 02:18:51,460 with higher odds of food insecurity. 1713 02:18:51,460 --> 02:18:56,340 Traumatic life events in the larger context of family and community, I mentioned earlier. 1714 02:18:56,340 --> 02:19:01,479 In several studies women exposed to childhood abuse and violence later in life were more 1715 02:19:01,479 --> 02:19:04,080 likely to report food insecurity. 1716 02:19:04,080 --> 02:19:10,700 And some people had found in qualitative studies that women described the impact of adverse 1717 02:19:10,700 --> 02:19:16,809 childhood experience on their school performance and ability to meet and maintain employment, 1718 02:19:16,809 --> 02:19:23,050 and then that experience negatively affecting their child, their own children's food insecurity, 1719 02:19:23,050 --> 02:19:25,689 suggesting intergenerational impacts. 1720 02:19:25,689 --> 02:19:31,170 Finally, related to later topics of this workshop on the food, environment, Janda and et. al. 1721 02:19:31,170 --> 02:19:39,110 in 2021 in a study done in Texas found that urban and rural adults living in zip codes 1722 02:19:39,110 --> 02:19:44,309 that only had supermarkets in neighboring zip codes were more likely to seek help with 1723 02:19:44,309 --> 02:19:50,040 food compared to those that had supermarkets locally, suggesting some larger context that 1724 02:19:50,040 --> 02:19:51,040 we need to better understand. 1725 02:19:51,040 --> 02:19:56,350 Last but not least, let's turn to older adults seniors age 60 or older. 1726 02:19:56,350 --> 02:20:00,899 Many of the studies featured in the slide I just showed included older populations. 1727 02:20:00,899 --> 02:20:07,200 But the studies cited here provide some unique impacts related to older adults, such as physical 1728 02:20:07,200 --> 02:20:13,990 strength and mobility limitations, activities of daily living, social isolation and cognitive 1729 02:20:13,990 --> 02:20:16,330 function and mortality. 1730 02:20:16,330 --> 02:20:23,460 In terms of unique gaps, Gunderson and Luria in 2012 in a workshop for the American Society 1731 02:20:23,460 --> 02:20:28,270 for Nutrition identified the impacts of food insecurity on seniors as a gap. 1732 02:20:28,270 --> 02:20:32,030 And nearly a decade later, I think we filled some of those gaps, but there's still some 1733 02:20:32,030 --> 02:20:34,080 remaining. 1734 02:20:34,080 --> 02:20:38,569 In addition to some that I already mentioned on the previous slide, ability to live independently 1735 02:20:38,569 --> 02:20:39,920 and stigma. 1736 02:20:39,920 --> 02:20:44,710 Pack and Kim in 2020 found that SNAP reduced the association between food insecurity and 1737 02:20:44,710 --> 02:20:48,760 physical health in seniors, but not mental health. 1738 02:20:48,760 --> 02:20:54,140 And they hypothesized that there's stigma associated with food insecurity may have reduced 1739 02:20:54,140 --> 02:20:57,040 seniors' self-esteem, increase their risk of depression. 1740 02:20:57,040 --> 02:21:02,090 And while I haven't mentioned stigma previously, stigma is important outcome to assess across 1741 02:21:02,090 --> 02:21:05,770 the lifespan in relation to experiencing food insecurity. 1742 02:21:05,770 --> 02:21:12,380 And to participate in the programs designed to address it, which leads us to the next 1743 02:21:12,380 --> 02:21:20,160 and almost last slide of mine, which is one of the things that makes it difficult to distinguish 1744 02:21:20,160 --> 02:21:25,010 the causes and effects of food insecurity has to do with what's called the cycle of 1745 02:21:25,010 --> 02:21:27,400 poverty depicted here. 1746 02:21:27,400 --> 02:21:31,820 In other words, poverty may lead to nutrition impacts, such as food insecurity and poor diet 1747 02:21:31,820 --> 02:21:32,820 quality. 1748 02:21:32,820 --> 02:21:40,990 But these, in turn, may lead to mental health issues, school and job performance, risk taking, 1749 02:21:40,990 --> 02:21:45,200 obesity, a lot of physical health ailments. 1750 02:21:45,200 --> 02:21:50,820 And all of those, in turn, may lead to lower wages and less employment and higher health 1751 02:21:50,820 --> 02:21:59,050 care costs, which then lead to more poverty and the cycle continues. 1752 02:21:59,050 --> 02:22:03,370 But food insecurity doesn't always begin with poverty, and it's clear from this figure that 1753 02:22:03,370 --> 02:22:08,630 one could jump into this cycle at multiple places because of multiple other insults and 1754 02:22:08,630 --> 02:22:12,479 at multiple times across the lifespan. 1755 02:22:12,479 --> 02:22:18,140 So one of the things that we have in place in the United States is to provide assistance 1756 02:22:18,140 --> 02:22:20,340 at various points along the cycle. 1757 02:22:20,340 --> 02:22:23,550 And some especially innovative ones will be shared in the next session. 1758 02:22:23,550 --> 02:22:28,900 But some of the examples of more traditional approaches include income assistance, such 1759 02:22:28,900 --> 02:22:35,160 as TANF nutrition assistance, such as SNAP, Education Assistance, such as Universal pre-K 1760 02:22:35,160 --> 02:22:40,300 and Pell Grants, Health Care, Medicaid, Job Assistance. 1761 02:22:40,300 --> 02:22:44,590 But what we have learned from qualitative studies is that there are many barriers to 1762 02:22:44,590 --> 02:22:49,250 assessing each program, even when adjunctive eligibility, for example, is in place. 1763 02:22:49,250 --> 02:22:54,260 And that unintended stress, stigma and shame can potentially result. 1764 02:22:54,260 --> 02:23:00,370 And those who most need the assistance, may have the least time, resources and ability 1765 02:23:00,370 --> 02:23:01,550 to navigate these multiple programs. 1766 02:23:01,550 --> 02:23:05,700 So I'm posing to the group, is it time to rethink how we provide services not just for 1767 02:23:05,700 --> 02:23:09,650 food insecurity because some other times, as I mentioned, food insecurity is a symptom 1768 02:23:09,650 --> 02:23:12,770 of other issues that we alone will not fix. 1769 02:23:12,770 --> 02:23:17,380 So instead of each program operating independently, could there be a more cohesive way to support 1770 02:23:17,380 --> 02:23:20,680 people cradle to grave in accessing services needed? 1771 02:23:20,680 --> 02:23:25,779 In short, I think the biggest gap in research is that we need to better understand how to 1772 02:23:25,779 --> 02:23:29,859 effectively disrupt this cycle. 1773 02:23:29,859 --> 02:23:34,229 In summary, in terms of research gaps and opportunities, they include the need for more 1774 02:23:34,229 --> 02:23:35,740 longitudinal studies. 1775 02:23:35,740 --> 02:23:37,910 There have been more recently, which is great. 1776 02:23:37,910 --> 02:23:45,200 But more are needed as it's tricky to disentangle these likely bi-directional relationships. 1777 02:23:45,200 --> 02:23:49,920 Food insecurity can occur at any point throughout life, but consequences may be more severe 1778 02:23:49,920 --> 02:23:55,069 in some stages and under certain circumstances and we need to better understand those. 1779 02:23:55,069 --> 02:23:57,190 Are there intergenerational impacts? 1780 02:23:57,190 --> 02:24:02,740 How do we consider the impact of food insecurity in relation to other life events. 1781 02:24:02,740 --> 02:24:06,430 And most importantly, not just deficits but assets. 1782 02:24:06,430 --> 02:24:13,149 And finally, how do we best break the poverty cycle across all life stages and intergenerationally 1783 02:24:13,149 --> 02:24:16,220 and ultimately prevent food insecurity before it happens? 1784 02:24:16,220 --> 02:24:23,070 With that, I'll turn it over to our moderator to entertain questions and ideas from the 1785 02:24:23,070 --> 02:24:24,540 rest of the group. 1786 02:24:24,540 --> 02:24:25,540 Thanks. 1787 02:24:25,540 --> 02:24:34,090 DR. CHARLOTTE PRATT: Thank you, all, very much for these excellent presentations. 1788 02:24:34,090 --> 02:24:37,910 We have quite a lot of questions here. 1789 02:24:37,910 --> 02:24:47,649 I think these presentations really draw attention to the need for a targeted approach to food 1790 02:24:47,649 --> 02:24:51,580 insecurity to make people become food insecure. 1791 02:24:51,580 --> 02:25:00,960 An American Indian population aged-population between 50 to 59, as well as others who are 1792 02:25:00,960 --> 02:25:03,521 disabled and African-American populations. 1793 02:25:03,521 --> 02:25:11,500 A few questions have come in and I'm going to go through the list as we have received 1794 02:25:11,500 --> 02:25:23,466 them, particularly paying attention to questions that are fairly relevant to the topic at hand. 1795 02:25:23,466 --> 02:25:27,666 So, let's see. 1796 02:25:29,400 --> 02:25:37,170 While I'm waiting for this to come on. 1797 02:25:37,170 --> 02:25:40,660 I'm going to... 1798 02:25:46,555 --> 02:25:51,596 DR. CRAIG GUNDERSEN: I can see the questions. 1799 02:25:51,596 --> 02:25:55,444 DR. CHARLOTTE PRATT: Yeah, hold on just a second. 1800 02:25:55,444 --> 02:25:57,904 DR GUNDERSEN: Yeah, definitely.I can read those ones. 1801 02:25:57,904 --> 02:26:08,540 DR. CHARLOTTE PRATT: There's a question that came on about for Dr. Gundersen relating to 1802 02:26:08,540 --> 02:26:14,740 homelessness and Asian population, why you don't have any studies, whether you have any 1803 02:26:14,740 --> 02:26:18,399 studies on that, if you can comment on it. 1804 02:26:18,399 --> 02:26:23,200 DR. CRAIG GUNDERSEN: So, the first thing is in looking at overlooked groups, I only had 15 minutes 1805 02:26:23,200 --> 02:26:27,550 to talk, so this is part of the reason why I couldn't include all groups and I just concentrated 1806 02:26:27,550 --> 02:26:29,120 on those groups. 1807 02:26:29,120 --> 02:26:34,939 Definitely, you know, the homeless population in some ways has higher rates of food insecurity. 1808 02:26:34,939 --> 02:26:39,830 And there's been some work done in that population, but we could do more work with that group. 1809 02:26:39,830 --> 02:26:41,330 I mean, oftentimes... 1810 02:26:41,330 --> 02:26:44,109 So there hasn't been enough work and more work to be done on this. 1811 02:26:44,109 --> 02:26:51,090 Asians, amongst Asian-Americans, this is somewhat of a tricky issue insofar as on average American 1812 02:26:51,090 --> 02:26:56,080 Indians have the lowest rates in the United States, far lower than white non-Hispanics. 1813 02:26:56,080 --> 02:27:02,610 The problem, though is that there's a lot of Asian groups with very high rates of food 1814 02:27:02,610 --> 02:27:04,200 insecurity that are often overlooked. 1815 02:27:04,200 --> 02:27:10,630 So, for example, the Hmong population has very high food insecurity rates in the United States, 1816 02:27:10,630 --> 02:27:13,260 as do Afghani-Americans have very high rates. 1817 02:27:13,260 --> 02:27:17,470 So in other words, there are certain segments of the Asian population that have higher rates, 1818 02:27:17,470 --> 02:27:19,090 and we should be talking about those. 1819 02:27:19,090 --> 02:27:25,710 Even if overall rates of food insecurity amongst Asian-Americans are the lowest of any ethnic 1820 02:27:25,710 --> 02:27:27,720 or racial group. 1821 02:27:27,720 --> 02:27:34,021 DR. CHARLOTTE PRATT: Yes, thanks for the response there. 1822 02:27:34,021 --> 02:27:43,220 There's another question here about how can SNAP be even more amazing by ending food insecurity? 1823 02:27:43,220 --> 02:27:51,320 And I do recall that your values are very similar to what the Thrifty Food Plan showed. 1824 02:27:51,320 --> 02:28:00,800 And so if you could elaborate on this comment here; What are some next steps you would recommend 1825 02:28:00,800 --> 02:28:02,750 to make SNAP even more amazing? 1826 02:28:02,750 --> 02:28:07,689 DR. CRAIG GUNDERSEN: The first thing I recommend is getting rid of this terminology nutrition 1827 02:28:07,689 --> 02:28:08,689 security. 1828 02:28:08,689 --> 02:28:11,351 Let's just get that out of the conversation. 1829 02:28:11,351 --> 02:28:16,890 It's a way of blaming vulnerable households for their own...for what they eat and everything. 1830 02:28:16,890 --> 02:28:20,290 It comes from groups...generally from groups of people who want to criticize those who 1831 02:28:20,290 --> 02:28:21,880 are vulnerable in our country. 1832 02:28:21,880 --> 02:28:26,780 Plus, there's no accepted way to define nutrition, insecurity and stuff. 1833 02:28:26,780 --> 02:28:32,529 And it's also there is nutrition insecurity across the full income spectrum. 1834 02:28:32,529 --> 02:28:34,149 I really dislike this term. 1835 02:28:34,149 --> 02:28:36,330 I think we need to keep talking about food insecurity. 1836 02:28:36,330 --> 02:28:39,300 Let's set that aside, though, let's talk about food insecurity. 1837 02:28:39,300 --> 02:28:41,069 This is not about nutrition. 1838 02:28:41,069 --> 02:28:42,311 Nutrition insecurity make that. 1839 02:28:42,311 --> 02:28:46,819 But let me then talk a little bit about how we can make SNAP even more amazing is to make 1840 02:28:46,819 --> 02:28:54,160 SNAP such that you would expand out eligibility for the program in some work that we've done on 1841 02:28:54,160 --> 02:29:00,061 this is expanding eligibility even out to the case that I proposed in food policy, which 1842 02:29:00,061 --> 02:29:03,600 dramatically reduced food insecurity because you have so many people who are slightly above 1843 02:29:03,600 --> 02:29:07,990 the threshold for gross income eligibility that are food insecure. 1844 02:29:07,990 --> 02:29:09,660 So bumping that up. 1845 02:29:09,660 --> 02:29:13,640 And similarly, is expanding benefit levels...increasing benefit levels akin 1846 02:29:13,640 --> 02:29:15,960 to what the USDA did, just increasing those benefit levels. 1847 02:29:15,960 --> 02:29:19,530 So I think all this is great to reduce food insecurity. 1848 02:29:19,530 --> 02:29:24,030 Let's continue to talk about food insecurity until we've eliminated food insecurity. 1849 02:29:24,030 --> 02:29:30,120 And let's stop, stop, stop talking about nutrition insecurity as long as we still have food insecurity. 1850 02:29:30,120 --> 02:29:31,899 DR. CHARLOTTE PRATT: Thank you. 1851 02:29:31,899 --> 02:29:40,649 Another question relates to the overlooked group the 50 to 59 year old's experience much 1852 02:29:40,649 --> 02:29:43,080 higher rates of food insecurity. 1853 02:29:43,080 --> 02:29:45,680 But how about the 60 plus? 1854 02:29:45,680 --> 02:29:51,641 Do they have access to more benefits compared to the 50 to 59? 1855 02:29:51,641 --> 02:29:59,521 DR. CRAIG GUNDERSEN: So, I mean, part of the...part of the reason why I... 1856 02:29:59,521 --> 02:30:04,430 But before turning to that, I think there's also some questions for Valerie and Lorenzo 1857 02:30:04,430 --> 02:30:09,170 if we could get some of those. 1858 02:30:09,170 --> 02:30:13,830 So in terms of why the 60 and above population, there are a few things that are different. 1859 02:30:13,830 --> 02:30:16,850 First of all, they're oftentimes eligible for like income support programs or Social 1860 02:30:16,850 --> 02:30:19,500 Security, SSI and things like that. 1861 02:30:19,500 --> 02:30:20,830 So that helps. 1862 02:30:20,830 --> 02:30:24,689 The second thing that those who are in this older group is, is that the eligibility for 1863 02:30:24,689 --> 02:30:29,850 SNAP is made easier for those who are over the age of 60, not something for 50 to 59. 1864 02:30:29,850 --> 02:30:34,689 So this is why I think that there are things that are available with 60 plus group that's 1865 02:30:34,689 --> 02:30:37,040 not available to the 50 to 59 group. 1866 02:30:37,040 --> 02:30:41,530 And so I think that, you know, based upon some early work that again, James Ziliak and I did, 1867 02:30:41,530 --> 02:30:47,413 is we showed that the 50 to 59 age group actually has the lowest participation rate in the SNAP of any group. 1868 02:30:47,413 --> 02:30:50,390 So let's figure out ways to help them out more. 1869 02:30:50,390 --> 02:30:57,899 DR. CHARLOTTE PRATT: Thank you. I have two questions for Dr. Jernigan, and I think two for Lorrene as well. 1870 02:30:57,899 --> 02:31:09,420 So, this person wants to know about...said, "Thank you for your insightful talk, Dr. Jernigan. Can you educate us further on the language? 1871 02:31:09,420 --> 02:31:18,140 I noticed that you used Natives to refer to American Indian and Alaskan Natives throughout your talk. 1872 02:31:18,140 --> 02:31:24,777 Is this the descriptor preferred by these communities?" 1873 02:31:24,777 --> 02:31:30,140 DR. VALERIE BLUE BIRD JERNIGAN: Hi, there. 1874 02:31:30,140 --> 02:31:41,600 It really is hard to answer that because there are over 565 federally recognized Native nations, 1875 02:31:41,600 --> 02:31:51,229 sovereign nations in the U.S., each with their own terminology, languages, names. 1876 02:31:51,229 --> 02:32:00,680 So, it really depends on what the preferred terminology is for each of those communities, 1877 02:32:00,680 --> 02:32:04,050 those nations, those groups. 1878 02:32:04,050 --> 02:32:12,609 A lot of folks use American Indian and Alaska Native because it is used in the treaties. 1879 02:32:12,609 --> 02:32:19,270 And so there's a preference in some areas for that language with that terminology. 1880 02:32:19,270 --> 02:32:24,890 But other folks prefer Indigenous or Native American. 1881 02:32:24,890 --> 02:32:32,920 It really is up to the individual and individual community what their preferences are. 1882 02:32:32,920 --> 02:32:36,810 DR. CHARLOTTE PRATT: Thank you very much. 1883 02:32:36,810 --> 02:32:46,256 There's a question here about your scoping review, and if you could kindly provide the... 1884 02:32:46,256 --> 02:32:52,759 Oh, what's happening? 1885 02:32:52,759 --> 02:32:58,098 If you could kindly provide the (INAUDIBLE). 1886 02:32:58,098 --> 02:33:29,226 [Audio Cuts Out] 1887 02:33:29,226 --> 02:33:36,660 DR. VALERIE BLUE BIRD JERNIGAN: Hi, there. It is actually not yet published. It just actually went in for publication today. 1888 02:33:36,660 --> 02:33:40,250 But I wanted to share a little bit with you of what we found. 1889 02:33:40,250 --> 02:33:45,160 DR. CHARLOTTE PRATT: Thank you. 1890 02:33:45,160 --> 02:33:52,000 I think I'm getting an echo here. 1891 02:33:52,000 --> 02:34:01,250 So, there's a question here for Lorrene. 1892 02:34:01,250 --> 02:34:06,040 "Excellent and comprehensive presentation. 1893 02:34:06,040 --> 02:34:13,370 I am wondering if you came across any information about food insecurity among households with 1894 02:34:13,370 --> 02:34:15,700 children with food allergies?" 1895 02:34:15,700 --> 02:34:19,180 DR. LORRENE RITCHIE: Yeah, that's a great question. 1896 02:34:19,180 --> 02:34:25,720 I do recall seeing one paper, which I did not include in my review and presentation. 1897 02:34:25,720 --> 02:34:31,080 And I do see you asked that question and I'm happy to share that I can't recall 1898 02:34:31,080 --> 02:34:37,100 the details of that paper, but I will definitely share it with others. 1899 02:34:37,100 --> 02:34:41,880 DR. CHARLOTTE PRATT: Thank you. 1900 02:34:41,880 --> 02:34:52,930 I think we will be able to do that in the on demand and when we post it, so that will 1901 02:34:52,930 --> 02:34:53,930 be available. 1902 02:34:53,930 --> 02:34:56,060 Another question for Lorrene: 1903 02:34:56,060 --> 02:35:00,170 "Thank you for this great overview and potential research opportunities. 1904 02:35:00,170 --> 02:35:07,470 Are there open data sources with both food insecurity and health outcomes that we can 1905 02:35:07,470 --> 02:35:14,090 use for looking at the effect of non-static during the life course?" 1906 02:35:14,090 --> 02:35:22,359 DR. LORRENE RITCHIE: Yeah. So earlier we had a talk by Alisha Coleman-Jensen that talked about some of the sources 1907 02:35:22,359 --> 02:35:29,130 of data that include the NHANES, for example, and the community CPS survey. 1908 02:35:29,130 --> 02:35:37,729 But all of those open source data sets, which do include to various extents measures of 1909 02:35:37,729 --> 02:35:42,680 food insecurity and health outcomes are at one point in time. 1910 02:35:42,680 --> 02:35:48,649 So one of the things that I think we need to think about as a field is how we can follow 1911 02:35:48,649 --> 02:35:51,250 people longer longitudinally. 1912 02:35:51,250 --> 02:35:55,319 There are some longitudinal data sets out there, and I did include some of those in 1913 02:35:55,319 --> 02:35:57,880 my presentation of the literature. 1914 02:35:57,880 --> 02:36:04,580 But most of the time, they follow people for a small percent, a small part of their lifespan, 1915 02:36:04,580 --> 02:36:07,310 not across multiple stages of their lifespan. 1916 02:36:07,310 --> 02:36:11,260 So that's definitely an area for future research. 1917 02:36:11,260 --> 02:36:13,200 DR. CHARLOTTE PRATT: Thank you. 1918 02:36:13,200 --> 02:36:17,100 Dr. Jernigan, there's another question for you here; 1919 02:36:17,100 --> 02:36:19,390 Thank you for the wonderful talk. 1920 02:36:19,390 --> 02:36:25,569 Can you please talk about ways to improve the food distribution program in American 1921 02:36:25,569 --> 02:36:31,590 Indian reservations, or how to replace it with (INAUDIBLE). 1922 02:36:32,590 --> 02:36:40,319 DR. VALERIE BLUE BIRD JERNIGAN: Sure. As a recipient of it myself, when I was a kid growing up here in Oklahoma, I 1923 02:36:40,319 --> 02:36:47,170 can tell you that it used to be a really different thing than it is now. 1924 02:36:47,170 --> 02:36:50,109 It has gotten a lot better. 1925 02:36:50,109 --> 02:36:58,050 The FDPIR program has made significant changes in the last decade or so. 1926 02:36:58,050 --> 02:37:04,590 But it still has a way to go and we still see a lot of differences across regions. 1927 02:37:04,590 --> 02:37:13,050 It's very, very hard to get refrigerated trucks to deliver a lot of the fresher produce to 1928 02:37:13,050 --> 02:37:16,109 some of the more isolated reservations. 1929 02:37:16,109 --> 02:37:18,160 And so that's a big thing that we've worked on. 1930 02:37:18,160 --> 02:37:23,550 Some of my worked in very rural parts of California looked at that. 1931 02:37:23,550 --> 02:37:34,340 We need equity around access to refrigerated trucks, repeated deliveries, much more frequent 1932 02:37:34,340 --> 02:37:35,930 deliveries. 1933 02:37:35,930 --> 02:37:43,190 There has been a lot of advocacy at the community level to improve the FDPIR and to include 1934 02:37:43,190 --> 02:37:47,120 more options, fresher options. 1935 02:37:47,120 --> 02:37:52,480 And a lot of that advocacy has come from Tribal leadership and Tribal community members. 1936 02:37:52,480 --> 02:37:55,100 And so I would say continue the advocacy. 1937 02:37:55,100 --> 02:38:02,609 I would say we need more studies that focus on improvement, particularly over time and 1938 02:38:02,609 --> 02:38:05,300 the association with help. 1939 02:38:05,300 --> 02:38:12,380 And I think looking at the sort of inequalities within inequalities. 1940 02:38:12,380 --> 02:38:16,790 And so, are there greater disparities in some regions vs. others? 1941 02:38:16,790 --> 02:38:20,450 Those are the things that we need to focus on in FDPIR 1942 02:38:20,450 --> 02:38:24,140 And so we need more research and we need more advocacy. 1943 02:38:24,140 --> 02:38:27,190 DR. CHARLOTTE PRATT: Thank you very much. 1944 02:38:27,190 --> 02:38:32,180 There's a question here again for Dr. Ritchie. 1945 02:38:32,180 --> 02:38:36,479 This question missed some parts of your presentation. 1946 02:38:36,479 --> 02:38:43,950 But she was wondering whether there are some data presented for early exposure of adversity 1947 02:38:43,950 --> 02:38:48,250 in relation to chronic disease in later adulthood. 1948 02:38:48,250 --> 02:38:56,750 So, tracking from early exposure and then looking at the trajectory of food insecurity 1949 02:38:56,750 --> 02:38:58,350 into later adulthood. 1950 02:38:58,350 --> 02:39:03,000 DR. LORRENE RITCHIE: Yeah, I mentioned a few studies about that. 1951 02:39:03,000 --> 02:39:04,000 Happy to share more. 1952 02:39:04,000 --> 02:39:10,810 But yes, we are starting to see emergent data suggesting that early childhood adversity 1953 02:39:10,810 --> 02:39:19,410 has impacts both on the individuals who experienced that adversity as adults increase food insecurity 1954 02:39:19,410 --> 02:39:26,960 among themselves as adults, but also some potential impacts on their ability to provide 1955 02:39:26,960 --> 02:39:28,930 for their own children. 1956 02:39:28,930 --> 02:39:31,780 And the suggestion that there may be intergenerational impacts. 1957 02:39:31,780 --> 02:39:39,890 Again, I put those on this side of the literature of where we need more research and more folks 1958 02:39:39,890 --> 02:39:41,630 at looking at those impacts. 1959 02:39:41,630 --> 02:39:44,029 Those are much harder studies to do. 1960 02:39:44,029 --> 02:39:53,790 I know for myself, you know, that kind of longitudinal look requires a lot more funding. 1961 02:39:53,790 --> 02:39:58,910 But perhaps that something NIH and USDA can help us with as researchers so that we can 1962 02:39:58,910 --> 02:40:02,390 answer some of those intergenerational impact questions. 1963 02:40:02,390 --> 02:40:04,200 DR. CHARLOTTE PRATT: Alright. 1964 02:40:04,200 --> 02:40:05,970 So thank you all very much. 1965 02:40:05,970 --> 02:40:09,110 I think we are out of time now. 1966 02:40:09,110 --> 02:40:12,770 And thank you for all your questions. 1967 02:40:12,770 --> 02:40:18,630 Certainly we aren't able to answer all of them, but we'll make sure that these questions 1968 02:40:18,630 --> 02:40:20,149 are posted somehow. 1969 02:40:20,149 --> 02:40:26,950 So we'll take a few minutes for a break and then come back to the next session. 1970 02:40:26,950 --> 02:40:28,260 Again, thank you very much. 1971 02:40:28,260 --> 02:40:34,550 DR. MARLENE SHWARTZ: So, hello, everyone, I'd like to welcome you to the panel. 1972 02:40:34,550 --> 02:40:39,620 The next two flash talk sessions will include eight minute presentations that highlight 1973 02:40:39,620 --> 02:40:42,359 innovative interventions. 1974 02:40:42,359 --> 02:40:47,720 And our first panelist is Dr. Caitlin Caspi of UConn's Rudd Center for Food Policy and 1975 02:40:47,720 --> 02:40:52,840 Obesity, my colleague and she will share her work exploring the influence of increasing 1976 02:40:52,840 --> 02:40:54,899 minimum wages on food insecurity outcomes. 1977 02:40:54,899 --> 02:41:00,670 The next flash talk is Dr. Amy Yaroch of the Gretchen Swanson Center for Nutrition. 1978 02:41:00,670 --> 02:41:10,100 She will share Early Results from the Gus Schumacher Nutrition Incentive Program GusNIP and produce-Rx. 1979 02:41:10,100 --> 02:41:17,641 And last we'll have Dr. Lisa Harnack, who will discuss the Restrictions and Incentives in the Supplemental Nutrition Assistance Program, or SNAP. 1980 02:41:17,641 --> 02:41:21,830 So, why don't we get started? 1981 02:41:21,830 --> 02:41:33,060 DR. CAITLIN CASPI: In today's presentation, I'm going to be discussing minimum wage increases 1982 02:41:33,060 --> 02:41:35,750 as an opportunity to address food insecurity. 1983 02:41:35,750 --> 02:41:43,930 I'm going to focus this talk on a specific evaluation that I'm leading—the Wages Study—which is 1984 02:41:43,930 --> 02:41:49,920 an NIH-funded five-year study that looks at whether minimum wage increase affects diet- 1985 02:41:49,920 --> 02:41:56,240 related outcomes, specifically food insecurity, food purchasing and body mass index among 1986 02:41:56,240 --> 02:42:01,450 low wage workers compared to a control community. 1987 02:42:01,450 --> 02:42:08,040 So, why are we discussing minimum wage in relation to diet-related health? 1988 02:42:08,040 --> 02:42:10,220 Isn't it too far upstream for a direct effect? 1989 02:42:10,220 --> 02:42:15,250 Aren't there other public policies that are more directly going to work on behavior? 1990 02:42:15,250 --> 02:42:21,850 Well, yes, and there's going to be plenty of discussion about those policies, I think in 1991 02:42:21,850 --> 02:42:22,850 this conference. 1992 02:42:22,850 --> 02:42:28,880 But minimum wage really can be powerful to consider for a number of reasons and I think 1993 02:42:28,880 --> 02:42:33,370 it's especially powerful in combination with some of the other policy interventions you're 1994 02:42:33,370 --> 02:42:42,840 going to hear about, as well as additional interventions at other levels of the social ecological model. 1995 02:42:42,840 --> 02:42:46,770 So, what's important to think about with minimum wage? 1996 02:42:46,770 --> 02:42:53,189 First, it's a key social determinant of health, and like many SES indicators, there's evidence 1997 02:42:53,189 --> 02:42:59,570 that it's associated with a range of positive health outcomes, from birth outcomes to all 1998 02:42:59,570 --> 02:43:02,340 cause mortality. 1999 02:43:02,340 --> 02:43:08,979 Minimum wage can affect diet and diet-related outcomes through multiple pathways that I'm 2000 02:43:08,979 --> 02:43:17,650 going to be walking through in just a couple of minutes. 2001 02:43:17,650 --> 02:43:21,010 And finally, minimum wage is a potential policy lever to address health equity. 2002 02:43:21,010 --> 02:43:24,960 So, unlike some policies that span the socioeconomic spectrum, minimum wage laws are really going to 2003 02:43:24,960 --> 02:43:31,080 be impactful for low wage workers, black and Hispanic workers, those who represent really 2004 02:43:31,080 --> 02:43:36,939 the greatest risk for diet related disease. 2005 02:43:36,939 --> 02:43:41,229 It's also important to study minimum wage right now because it's modifiable and it's 2006 02:43:41,229 --> 02:43:43,800 pretty high on the political agenda. 2007 02:43:43,800 --> 02:43:49,649 We're seeing a lot of states increase their minimum wage above federal levels, and we're 2008 02:43:49,649 --> 02:43:53,649 seeing local jurisdictions, counties and cities increase their minimum wage. 2009 02:43:53,649 --> 02:43:59,520 And we're also hearing about businesses like Amazon and Target and Costco that are raising 2010 02:43:59,520 --> 02:44:04,120 their minimum wage to $15 an hour or even above. 2011 02:44:04,120 --> 02:44:11,529 So, this is the hypothesized relationship between minimum wage and the outcomes that 2012 02:44:11,529 --> 02:44:14,740 we're looking at in measuring in the wages study. 2013 02:44:14,740 --> 02:44:19,450 So, we're doing annual surveys, getting pay stubs, doing height and weight and collecting 2014 02:44:19,450 --> 02:44:22,590 diet receipts or food purchasing receipts among our participants. 2015 02:44:22,590 --> 02:44:29,010 And what we really think we're going to see is that increased minimum wage is going to increase 2016 02:44:29,010 --> 02:44:34,800 household income, which is going to have a net positive effect on diet quality and other 2017 02:44:34,800 --> 02:44:37,340 obesity-related outcomes. 2018 02:44:37,340 --> 02:44:47,399 So, this study is designed as a natural experiment where we're following workers that have been 2019 02:44:47,399 --> 02:44:51,140 recruited in two different cities Minneapolis, Minnesota has a minimum wage ordinance under 2020 02:44:51,140 --> 02:44:53,290 way where they're raising minimum wage. 2021 02:44:53,290 --> 02:44:58,350 The city is incrementally to $15 an hour until 2023. 2022 02:44:58,350 --> 02:45:06,229 And the comparison community is Raleigh, North Carolina, where there is a state preemption 2023 02:45:06,229 --> 02:45:11,200 that prohibits the local jurisdictions from increasing their minimum wage. 2024 02:45:11,200 --> 02:45:14,040 And so in that sense, it makes a good control site. 2025 02:45:14,040 --> 02:45:20,910 And it also makes a good control site because it actually has a fairly similar set of demographics 2026 02:45:20,910 --> 02:45:26,910 to Minneapolis, except that it does have a higher proportion of black residents. 2027 02:45:26,910 --> 02:45:35,700 So, for the study, we recruited workers who were making less than $11.50 an hour in both 2028 02:45:35,700 --> 02:45:36,700 cities. 2029 02:45:36,700 --> 02:45:42,439 It was a community-based sample and we're still in the midst of data collection and 2030 02:45:42,439 --> 02:45:45,500 we'll be following these same participants until 2022. 2031 02:45:45,500 --> 02:45:50,950 And at the end of the study, we're going to do a difference in different analysis to look 2032 02:45:50,950 --> 02:45:56,200 at change in the outcomes across the two cities. 2033 02:45:56,200 --> 02:46:01,979 So, while the study is still underway, I would... just wanted to present some descriptive statistics 2034 02:46:01,979 --> 02:46:06,620 from our first three time PAC points from 2018 to 2020. 2035 02:46:06,620 --> 02:46:13,500 The average hourly wage of study participants was slightly higher in Minneapolis at baseline, 2036 02:46:13,500 --> 02:46:19,330 but it did increase in both of the cities in the two subsequent years. 2037 02:46:19,330 --> 02:46:26,399 So, now we're looking at food insecurity in the two cities, which was very high at baseline 2038 02:46:26,399 --> 02:46:31,300 using the six-item USDA measure, it was more than 70 percent at baseline in both cities. 2039 02:46:31,300 --> 02:46:37,920 And it did decrease in both cities in 2019 and then again in 2020. 2040 02:46:37,920 --> 02:46:42,529 And this difference was not statistically significant between cities and it's still 2041 02:46:42,529 --> 02:46:47,160 high, but not as high as at baseline. 2042 02:46:47,160 --> 02:46:52,370 This is looking at SNAP participation, which we know that many of our participants were 2043 02:46:52,370 --> 02:46:53,370 relying on. 2044 02:46:53,370 --> 02:46:59,689 It did appear to go down slightly between 2018 and 2019 and then went up again in both 2045 02:46:59,689 --> 02:47:07,609 cities during 2020, which is perhaps not surprising given that we know that access to SNAP and 2046 02:47:07,609 --> 02:47:12,100 eligibility for SNAP participation did change during the pandemic, which tended to make 2047 02:47:12,100 --> 02:47:15,040 it more accessible to people. 2048 02:47:15,040 --> 02:47:22,550 So, we know that many of our participants were relying on both resources from their 2049 02:47:22,550 --> 02:47:31,061 income, as well as food assistance resources to make purchases and to put food on the table. 2050 02:47:31,061 --> 02:47:35,120 And in 2019, we conducted a qualitative study to dig into this a little bit more among 112 2051 02:47:35,120 --> 02:47:37,380 of our wages study participants and we found a number of themes. 2052 02:47:37,380 --> 02:47:39,340 I'm just going to highlight two of them. 2053 02:47:39,340 --> 02:47:45,800 The first is that when we ask people about their SNAP benefits, they so commonly talked 2054 02:47:45,800 --> 02:47:52,350 about SNAP really as just one part of the overall safety net that made it possible for 2055 02:47:52,350 --> 02:47:53,630 them to make ends meet. 2056 02:47:53,630 --> 02:48:00,399 So, they also talked about the importance of housing and utility assistance, Medicare 2057 02:48:00,399 --> 02:48:01,399 charitable foods. 2058 02:48:01,399 --> 02:48:05,890 With this idea that we focus very much on SNAP as the largest federal food assistance 2059 02:48:05,890 --> 02:48:10,890 support for people, but that it's really the combination of all of these that's making 2060 02:48:10,890 --> 02:48:14,899 it work for people, and the sort of demonstrative quote here is, "You've got food, but you can't 2061 02:48:14,899 --> 02:48:17,250 cook it if the lights are off." 2062 02:48:17,250 --> 02:48:21,591 And I think sometimes we forget about that and we're focused on nutrition programs and 2063 02:48:21,591 --> 02:48:24,420 nutrition outcomes. 2064 02:48:24,420 --> 02:48:29,210 And then a second theme is that while people thought that the minimum wage was likely to 2065 02:48:29,210 --> 02:48:35,729 have a benefit, they were a little bit skeptical of how impactful it would be, given that $15 2066 02:48:35,729 --> 02:48:44,680 an hour is not a living wage for many household and household sizes in Minneapolis, and people 2067 02:48:44,680 --> 02:48:50,270 were specifically concerned that the cost of living could go up as a result of the minimum 2068 02:48:50,270 --> 02:48:51,600 wage. 2069 02:48:51,600 --> 02:49:00,290 So, in our analysis, we're going to have to think about the effects of other types of 2070 02:49:00,290 --> 02:49:01,290 policies. 2071 02:49:01,290 --> 02:49:07,960 Many policies were passed during COVID that could affect our outcomes, and I'm using this 2072 02:49:07,960 --> 02:49:15,340 gaps and opportunities slide to really think about how we can, in the next phase of research, 2073 02:49:15,340 --> 02:49:23,561 think about not just how single policies affects health outcomes, but really do more sophisticated 2074 02:49:23,561 --> 02:49:32,069 studies that look at how these layers of policies form policy context that can either enhance 2075 02:49:32,069 --> 02:49:34,229 or inhibit health. 2076 02:49:34,229 --> 02:49:40,311 And so, to think about how things at the national level like extra unemployment benefits or 2077 02:49:40,311 --> 02:49:47,120 SNAP expansion or the stimulus checks worked synergistically with school food distribution 2078 02:49:47,120 --> 02:49:49,000 and charitable food actions during COVID. 2079 02:49:49,000 --> 02:49:54,720 I mean, so again, I think that looking at the combination of these policies and how 2080 02:49:54,720 --> 02:50:01,280 they can work together is the next area of exploration that I'm interested in. 2081 02:50:01,280 --> 02:50:08,375 So, just to sum up minimum wage increases have the potential to have a positive effect 2082 02:50:08,375 --> 02:50:13,426 on health outcomes through many different pathways and evaluation of our Minneapolis 2083 02:50:13,426 --> 02:50:16,159 minimum wage ordinance is ongoing. 2084 02:50:16,159 --> 02:50:21,507 I was surprised to learn how much our study participants were...how common the experience 2085 02:50:21,507 --> 02:50:23,634 of food insecurity was. 2086 02:50:23,634 --> 02:50:27,030 So, this is a population that is really at a high risk. 2087 02:50:27,030 --> 02:50:33,950 When we're thinking about minimum wage and we're thinking about changes in income, we 2088 02:50:33,950 --> 02:50:38,189 have to think about the whole spectrum of income-based benefits that that could possibly 2089 02:50:38,189 --> 02:50:39,189 affect. 2090 02:50:39,189 --> 02:50:46,037 And then finally, as we see minimum wage increase across states and local areas, it really presents 2091 02:50:46,037 --> 02:50:56,134 an opportunity to evaluate minimum wage policies and their health effects, both in isolation as well as in the context of other policy supports. Thank you. 2092 02:50:56,134 --> 02:50:59,114 DR. AMY YAROCH: Good morning, good afternoon, everyone. 2093 02:50:59,114 --> 02:51:04,290 I am Amy Yaroch, project director of the NTAE Center for the Gus Schumacher Nutrition Incentive 2094 02:51:04,290 --> 02:51:08,899 Program, otherwise known as GusNIP and executive director of the Gretchen Swanson Center for 2095 02:51:08,899 --> 02:51:11,920 Nutrition in Omaha, Nebraska. 2096 02:51:11,920 --> 02:51:16,140 The GusNIP NTAE Center is led by Gretchen Swanson Center for Nutrition through a 4- 2097 02:51:16,140 --> 02:51:18,570 year cooperative agreement with USDA NIFA. 2098 02:51:18,570 --> 02:51:25,200 The GusNIP NTAE came about as a direct result of the 2018 Farm Bill legislation. 2099 02:51:25,200 --> 02:51:30,750 Essentially, the GusNIP NTAE serves as a coordinating center to help both existing and prospective 2100 02:51:30,750 --> 02:51:37,359 GusNIP grantees navigate reporting and evaluation and obtain technical assistance. 2101 02:51:37,359 --> 02:51:41,029 I want to quickly show you the breadth of partners involved in this endeavor, so you could get 2102 02:51:41,029 --> 02:51:46,000 a sense of the incredible expertise across both the reporting and evaluation and technical 2103 02:51:46,000 --> 02:51:48,240 assistance and innovation teams. 2104 02:51:48,240 --> 02:51:53,229 The Nutrition Incentive Hub was created by the GusNIP NTAE Center to support nutrition 2105 02:51:53,229 --> 02:52:00,160 incentive and produce prescription grantees and applicants, and it is a coalition of practitioners, 2106 02:52:00,160 --> 02:52:04,760 grocery and farmers' market experts, researchers, evaluators and others from across the country. 2107 02:52:04,760 --> 02:52:08,930 At the top, you could see a USDA NIFA, our funder. 2108 02:52:08,930 --> 02:52:13,410 We at the Gretchen Swanson Center Service, the GusNIP NTAE Center as well as the lead for 2109 02:52:13,410 --> 02:52:14,410 reporting and evaluation. 2110 02:52:14,410 --> 02:52:20,350 The boxes on the left signify the many amazing researchers throughout the U.S. we've leveraged 2111 02:52:20,350 --> 02:52:26,189 who have in-depth public health nutrition experience to help us on reporting and evaluation. 2112 02:52:26,189 --> 02:52:30,580 Technical assistance and innovation is led by Fair Food Network, and they've assembled 2113 02:52:30,580 --> 02:52:35,670 a strong team of partners with deep expertise in farmers' market and grocery retail to help 2114 02:52:35,670 --> 02:52:38,630 on technical assistance. 2115 02:52:38,630 --> 02:52:44,450 I want to next give you a quick sense of the scale and reach of GusNIP to show you just 2116 02:52:44,450 --> 02:52:46,510 how much this field is growing. 2117 02:52:46,510 --> 02:52:52,979 In just two years of awards so far, GusNIP is reaching coast to coast with a significant 2118 02:52:52,979 --> 02:53:00,000 investment of 82.4 million in 2019 and 2020, and new awards are on the way for 2021. 2119 02:53:00,000 --> 02:53:06,494 Whereas we saw in the previous slide the locations of the primary awardee for GusNIP funding 2120 02:53:06,494 --> 02:53:13,151 in 2019 and 2020 only, this slide shows the total reach of USDA's Food and Insecurity Nutrition 2121 02:53:13,151 --> 02:53:20,351 Incentive, or FINI Program, the predecessors of GusNIP and GusNIP funding from 2015 to the present. 2122 02:53:20,351 --> 02:53:25,649 It is really exciting to see that this funding and program implementation is reaching across 2123 02:53:25,649 --> 02:53:27,610 nearly the entire U.S. 2124 02:53:27,610 --> 02:53:34,570 Next, I will describe the GusNIP program types, reporting and evaluation and results from 2125 02:53:34,570 --> 02:53:35,570 year one. 2126 02:53:35,570 --> 02:53:41,609 There are two main types of GusNIP programs, Nutrition Incentive or SNAP incentive programs 2127 02:53:41,609 --> 02:53:47,140 increase the value of SNAP EBT at the point of sale by providing incentives to use at 2128 02:53:47,140 --> 02:53:51,840 participating sites, such as grocery stores, farmers' markets and other venues, to purchase 2129 02:53:51,840 --> 02:53:52,890 more fruits and vegetables. 2130 02:53:52,890 --> 02:53:59,210 For instance, if a participant spends $10 of SNAP on fruits or vegetables, they get 2131 02:53:59,210 --> 02:54:02,470 $20 of produce at participating sites. 2132 02:54:02,470 --> 02:54:08,720 The other type of program are produce prescription, which are not specific to SNAP participants. 2133 02:54:08,720 --> 02:54:14,460 Rather, patients who are low income and experiencing food insecurity and quite often a chronic 2134 02:54:14,460 --> 02:54:18,510 condition are prescribed fruits and vegetables by a health care professional, which then 2135 02:54:18,510 --> 02:54:20,590 could be redeemed at participating sites. 2136 02:54:20,590 --> 02:54:25,689 One of the main reasons we're conducting reporting and evaluation is to better understand and 2137 02:54:25,689 --> 02:54:28,070 elevate the impact of these programs. 2138 02:54:28,070 --> 02:54:31,920 And it is one thing to see this impact through the individual programs themselves, which 2139 02:54:31,920 --> 02:54:32,920 is great. 2140 02:54:32,920 --> 02:54:38,080 But when you have the ability to aggregate the data across these programs, working throughout 2141 02:54:38,080 --> 02:54:42,080 the U.S. and to me, that's really amazing to see. 2142 02:54:42,080 --> 02:54:46,510 With aggregate data, we have the power to see changes in some concrete outcomes. 2143 02:54:46,510 --> 02:54:50,240 This can translate into increased fruit and vegetable purchasing and ultimately, fruit 2144 02:54:50,240 --> 02:54:56,130 and vegetable intake, along with decreased food insecurity and for produce prescription, 2145 02:54:56,130 --> 02:55:00,410 improved health outcomes and decreased health care use and costs. 2146 02:55:00,410 --> 02:55:02,610 And to me, that's where the rubber meets the road. 2147 02:55:02,610 --> 02:55:08,170 Since we can underscore the need for promotion and implementation of these programs, along 2148 02:55:08,170 --> 02:55:10,580 with making the case for continued funding. 2149 02:55:10,580 --> 02:55:15,620 This is one of the things that as a researcher and evaluator, I'm truly excited about. 2150 02:55:15,620 --> 02:55:20,689 We targeted the data we collected in year one to account for the pandemic. 2151 02:55:20,689 --> 02:55:26,420 Despite the challenges of COVID, we were successful in collecting program data from over 700 participating 2152 02:55:26,420 --> 02:55:31,790 sites, meaning grocery stores, farmers' markets and clinics offering incentive programs. 2153 02:55:31,790 --> 02:55:35,110 You can see the breakdown of what types of sites reported data. 2154 02:55:35,110 --> 02:55:39,739 For brick and mortar outlets, the majority of sites were large supermarkets and independent 2155 02:55:39,739 --> 02:55:41,220 grocery stores. 2156 02:55:41,220 --> 02:55:45,609 For produce prescription, they were mainly small food stores and for Farm-Direct, the 2157 02:55:45,609 --> 02:55:51,590 sites were mainly farmer's markets and there were 33 clinics. 2158 02:55:51,590 --> 02:55:56,950 This slide displays some of the promising data we saw in year one in the number of sites 2159 02:55:56,950 --> 02:56:01,229 again stores, markets, clinics offering incentives throughout the year. 2160 02:56:01,229 --> 02:56:06,149 Despite being in the middle of a pandemic, these GusNIP grantees managed to dramatically 2161 02:56:06,149 --> 02:56:11,160 increase the number of sites offering these programs, which means they brought many more 2162 02:56:11,160 --> 02:56:14,569 incentive dollars to many more families in many more places. 2163 02:56:14,569 --> 02:56:19,720 Some of the ebbs and flows you see are based on seasonality and COVID shutdowns. 2164 02:56:19,720 --> 02:56:24,870 Again, this is pretty amazing given how much capacity it takes to launch a new site in 2165 02:56:24,870 --> 02:56:27,000 non-COVID times. 2166 02:56:27,000 --> 02:56:32,869 This slide displays the total incentive program sales among 2019 GusNIP-funded projects in 2167 02:56:32,869 --> 02:56:35,863 the local economic impact generated from those sales. 2168 02:56:35,863 --> 02:56:40,210 Local economic impact includes both direct effects, sales at participating sites and 2169 02:56:40,210 --> 02:56:41,489 indirect effects. 2170 02:56:41,489 --> 02:56:47,700 How sites spend the extra revenue, such as on hiring, marketing and other related things. 2171 02:56:47,700 --> 02:56:50,550 As the figure shows, the total incentive program sales that is, the dollar amount of incentives 2172 02:56:50,550 --> 02:56:57,460 redeemed among the 2019 nutrition incentive in produce prescription projects was approximately 2173 02:56:57,460 --> 02:57:04,560 $4 million, which generates an impact estimate of almost $8 million. 2174 02:57:04,560 --> 02:57:08,660 This is a win across the board and as such is why incentive programs typically generate 2175 02:57:08,660 --> 02:57:11,350 bipartisan support. 2176 02:57:11,350 --> 02:57:15,729 If you are interested in finding out more about year one results, you can view our year 2177 02:57:15,729 --> 02:57:21,229 one impact findings at nutritionincentivehub.org. 2178 02:57:21,229 --> 02:57:25,350 We recently updated our website and launched the GusNIP grantee portal. 2179 02:57:25,350 --> 02:57:31,840 Our website, which has the same domain name nutritionincentivehub.org has enhanced navigation, 2180 02:57:31,840 --> 02:57:35,430 interaction and search ability and also is publicly available. 2181 02:57:35,430 --> 02:57:40,800 So, if you're interested in this area at all, feel free to tool around on the website. 2182 02:57:40,800 --> 02:57:46,000 A few interesting things to point out are the GusNIP grantee map and project information, 2183 02:57:46,000 --> 02:57:50,800 which allows you to see distinct projects state by state, filter results in various 2184 02:57:50,800 --> 02:57:56,391 ways and even export to excel, and we have more than 100 resources that are currently 2185 02:57:56,391 --> 02:58:01,830 available on various topics and more to come, including a searchable resource library, which 2186 02:58:01,830 --> 02:58:09,000 will be available this fall and allow users to easily search and filter results for hundreds 2187 02:58:09,000 --> 02:58:11,380 of resources. 2188 02:58:11,380 --> 02:58:14,220 And then communities of practice, this is found under our Join Our Community and is 2189 02:58:14,220 --> 02:58:20,231 a great way to connect with other practitioners and experts in the area. 2190 02:58:20,231 --> 02:58:24,649 For technical assistance, you can easily request or connect with our team members through our 2191 02:58:24,649 --> 02:58:29,979 Request Help Connect Form, which is read and responded to by a real person, and another 2192 02:58:29,979 --> 02:58:34,729 feature that's coming this fall are discussion groups as an additional way to connect peer 2193 02:58:34,729 --> 02:58:35,890 to peer. 2194 02:58:35,890 --> 02:58:41,819 In addition, there's a separate integrated portal with a seamless, secure login where 2195 02:58:41,819 --> 02:58:47,350 GusNIP grantees, sites and other specific partners have access to content and information 2196 02:58:47,350 --> 02:58:49,439 tailored to their role. 2197 02:58:49,439 --> 02:58:54,580 There is robust and secure data reporting functionality and dashboards for grantees 2198 02:58:54,580 --> 02:58:57,029 and sites can visualize their project progress. 2199 02:58:57,029 --> 02:59:01,180 I appreciate your time and attention and feel free to reach out if you have any questions 2200 02:59:01,180 --> 02:59:03,380 and enjoy the rest of the workshop. 2201 02:59:03,380 --> 02:59:04,380 Thanks. 2202 02:59:04,380 --> 02:59:11,529 DR. LISA HARNACK: It's a pleasure to be here today to talk to you about what we know about restrictions 2203 02:59:11,529 --> 02:59:15,750 and incentives in the SNAP program. 2204 02:59:15,750 --> 02:59:20,310 A brief reminder of what the SNAP program is. 2205 02:59:20,310 --> 02:59:24,470 It's a federal program that provides funds to lowincome families for the purchase of 2206 02:59:24,470 --> 02:59:25,470 food. 2207 02:59:25,470 --> 02:59:30,940 The amount of funds provided monthly are designed to provide supplemental funds for food purchasing, 2208 02:59:30,940 --> 02:59:35,609 meaning that for most households, it's expected that they will use some of out of pocket funds 2209 02:59:35,609 --> 02:59:37,370 to purchase food. 2210 02:59:37,370 --> 02:59:43,680 The funds are provided on an electronic benefit transfer card that's scanned at checkout like 2211 02:59:43,680 --> 02:59:46,040 a credit or debit card. 2212 02:59:46,040 --> 02:59:50,980 Most foods may be purchased with program benefits. 2213 02:59:50,980 --> 02:59:57,430 Exceptions are restaurant foods, dietary supplements and alcohol. 2214 02:59:57,430 --> 03:00:06,120 There's been discussion of ways to reshape the program so that it may better support 2215 03:00:06,120 --> 03:00:07,569 family nutrition. 2216 03:00:07,569 --> 03:00:13,920 Research clearly shows that the program is effective in reducing food insecurity. 2217 03:00:13,920 --> 03:00:23,110 But it's less clear that the program has benefit on the nutritional quality of the diets of 2218 03:00:23,110 --> 03:00:25,020 program participants. 2219 03:00:25,020 --> 03:00:30,160 One idea that's been discussed is prohibiting the purchase of less healthful foods with 2220 03:00:30,160 --> 03:00:34,650 program benefits, for example, not allowing sugar sweetened beverages or other sugary 2221 03:00:34,650 --> 03:00:37,510 foods to be purchased with program benefits. 2222 03:00:37,510 --> 03:00:47,740 There's also the discussion of pairing these types of restrictions with a fruit and vegetable 2223 03:00:47,740 --> 03:00:54,500 incentive, such as a 30 percent bonus on the purchase of fruits and vegetables. 2224 03:00:54,500 --> 03:01:01,300 Very little is known about the effect of restrictions or restrictions paired with incentives on 2225 03:01:01,300 --> 03:01:07,439 the food purchasing and diet quality of SNAP participants. 2226 03:01:07,439 --> 03:01:15,950 We carried out two randomized controlled trials to begin to address this research GAP. 2227 03:01:15,950 --> 03:01:24,760 The first study we carried out was called the Filling the GAP study, and we had a follow 2228 03:01:24,760 --> 03:01:25,760 up study the GAPS for families. 2229 03:01:25,760 --> 03:01:28,180 I haven't the time to fully describe these studies, but in both studies we randomize 2230 03:01:28,180 --> 03:01:33,989 households that were eligible are near eligible for SNAP, but not participating. And we randomized 2231 03:01:33,989 --> 03:01:42,701 them to food benefit programs that varied with respect to what foods can be purchased and whether there was a fruit and vegetable incentive. 2232 03:01:42,701 --> 03:01:50,989 The benefit was provided through a study provided debit card with funds loaded monthly. 2233 03:01:50,989 --> 03:01:56,670 Those randomized to a restriction group were not allowed to buy sugar sweetened beverages, 2234 03:01:56,670 --> 03:02:00,020 sweet baked goods or candies with their program benefit. 2235 03:02:00,020 --> 03:02:04,630 Those randomized to receive an incentive for fruit and vegetable purchasing were given 2236 03:02:04,630 --> 03:02:16,750 a 30 percent bonus for any fruits and vegetables purchased using the program benefit card. 2237 03:02:16,750 --> 03:02:22,290 For the GAPS for families study, the first study, we found that in the restriction group, 2238 03:02:22,290 --> 03:02:29,030 there were some improvements in diet quality and food purchasing relative to the control 2239 03:02:29,030 --> 03:02:34,290 group, but not as many improvements as seen in the restriction paired with incentive group. 2240 03:02:34,290 --> 03:02:39,970 And that restriction paired with incentive group there was lower calorie intake, lower 2241 03:02:39,970 --> 03:02:45,160 sugar sweetened beverage intake, lower intake of those restricted foods, higher fruit intake 2242 03:02:45,160 --> 03:02:51,200 and higher overall diet quality in comparison to the control group that received money monthly 2243 03:02:51,200 --> 03:02:56,239 for purchasing food following the usual SNAP food purchasing rules. 2244 03:02:56,239 --> 03:03:01,850 There was also lower purchasing of sugar sweetened beverages and higher fruit purchasing. 2245 03:03:01,850 --> 03:03:08,800 So, this first study certainly suggested that restrictions paired with incentives could 2246 03:03:08,800 --> 03:03:12,390 improve the diet quality of SNAP participants. 2247 03:03:12,390 --> 03:03:23,590 But our second study, which was a more rigorous study, it did not find benefits of restrictions 2248 03:03:23,590 --> 03:03:28,800 or restrictions paired with incentives on the diet quality of program participants, 2249 03:03:28,800 --> 03:03:34,811 and I should say that in this study, we looked at the diet quality of not just the adults 2250 03:03:34,811 --> 03:03:40,300 in the household primarily responsible for food shopping, that's who we evaluated in 2251 03:03:40,300 --> 03:03:41,300 the first study. 2252 03:03:41,300 --> 03:03:45,270 We also looked at the diet quality of a child, two to 11 years of age in the household and 2253 03:03:45,270 --> 03:03:51,170 for neither the adult or child, did we see any improvements in diet quality or the other 2254 03:03:51,170 --> 03:03:53,410 dietary intake outcomes we looked at. 2255 03:03:53,410 --> 03:03:59,170 We did find lower purchasing of sugar sweetened beverages and sweet baked goods in both the 2256 03:03:59,170 --> 03:04:09,350 restriction and restriction paired with incentive group in comparison to the control group. 2257 03:04:09,350 --> 03:04:16,384 In both studies, we also asked those participating in the study what they thought about the restrictions, 2258 03:04:16,384 --> 03:04:24,618 if they were randomized to one of the groups that received restrictions because it's so important to understand what, you know, the SNAP participant perspective is on any program 2259 03:04:24,618 --> 03:04:34,590 rules, purchasing rules and what we found in the first study when we asked, what did you think of the restrictions? 2260 03:04:34,590 --> 03:04:37,760 We found that 58 percent endorsed the restrictions, 37 percent gave a response to this question that 2261 03:04:37,760 --> 03:04:45,370 indicated they were kind of neutral on it and then 5% indicated certain things that 2262 03:04:45,370 --> 03:04:52,410 indicated they were not supportive of it, of the restrictions. 2263 03:04:52,410 --> 03:05:02,160 In our filling the GAPS for families study, the second study findings were similar. 2264 03:05:02,160 --> 03:05:05,340 So, to conclude, I didn't have a chance to describe our study design and go into that, 2265 03:05:05,340 --> 03:05:09,271 but there's limitations with the way we designed the study. 2266 03:05:09,271 --> 03:05:13,000 Ideally, this evaluation of restrictions and restrictions paired with incentives would 2267 03:05:13,000 --> 03:05:18,490 be carried out within the actual SNAP program, where the as trainable validity of findings would 2268 03:05:18,490 --> 03:05:20,060 be better. 2269 03:05:20,060 --> 03:05:25,330 And so that is a recommendation our research team has, is that that type of evaluation 2270 03:05:25,330 --> 03:05:30,390 needs to be carried out to fully evaluate the idea of restrictions and restrictions 2271 03:05:30,390 --> 03:05:33,360 paired with incentives. 2272 03:05:33,360 --> 03:05:39,840 I want to acknowledge the study team, the community collaborators and funding for these studies. 2273 03:05:39,840 --> 03:05:40,840 Thank you for your attention. 2274 03:05:44,067 --> 03:05:48,830 DR. MARLENE SHWARTZ: Well, thank you to our three presenters for sharing their really interesting work. 2275 03:05:48,830 --> 03:05:54,390 Before we move on to the Q&A, we're going to have a second set of flash talk presentations. 2276 03:05:54,390 --> 03:05:57,670 These are highlighting interventions in the health care setting. 2277 03:05:57,670 --> 03:06:02,560 So, first, we'll hear from Dr. Hilary Seligman of the University of California, San Francisco. 2278 03:06:02,560 --> 03:06:07,439 She will speak on her innovative models of care to reduce food insecurity. 2279 03:06:07,439 --> 03:06:12,491 Then we'll hear from Dr. Francesca Gany of Memorial Sloan Kettering Cancer Center, and 2280 03:06:12,491 --> 03:06:18,080 she'll talk about her intervention research with cancer patients and medically tailored 2281 03:06:18,080 --> 03:06:24,181 meals and other approaches, and then to close the session, Dr. Leonard Egede of the Medical 2282 03:06:24,181 --> 03:06:29,600 College of Wisconsin will discuss his intervention work to address type 2 diabetes among AfricanAmericans 2283 03:06:29,600 --> 03:06:34,440 experiencing food insecurity. 2284 03:06:34,440 --> 03:06:42,410 DR. HILARY SELIGMAN: Hi, my name is Hilary Seligman. 2285 03:06:42,410 --> 03:06:47,100 Thank you for inviting me to speak to you today very quickly about new models of care 2286 03:06:47,100 --> 03:06:48,100 to reduce food insecurity. 2287 03:06:48,100 --> 03:06:55,500 The interventions I'm going to discuss today are based on a screen and intervene conceptual 2288 03:06:55,500 --> 03:07:01,620 model, where the theory is that if we can identify food insecure patients in the clinical 2289 03:07:01,620 --> 03:07:09,080 setting and refer them to some type of an intervention that can support healthier 2290 03:07:09,080 --> 03:07:17,310 dietary intake and improved food security that we may ultimately improve health and 2291 03:07:17,310 --> 03:07:18,720 utilization outcomes. 2292 03:07:18,720 --> 03:07:24,540 The interventions that people are generally referred to in the clinical setting fall under 2293 03:07:24,540 --> 03:07:32,490 three general buckets; onsite programs that are implemented in the health care setting, 2294 03:07:32,490 --> 03:07:36,521 community programs which are obviously implemented in the community and then the federal nutrition 2295 03:07:36,521 --> 03:07:37,521 programs. 2296 03:07:37,521 --> 03:07:43,069 It is the onsite programs and the community based programs that we'll focus on today. 2297 03:07:43,069 --> 03:07:46,580 These are generally considered Food Is Medicine interventions. 2298 03:07:46,580 --> 03:07:53,899 In general, a Food Is Medicine intervention is considered the integration of a specific 2299 03:07:53,899 --> 03:08:00,229 food and nutrition intervention in or in close collaboration with the health care system. 2300 03:08:00,229 --> 03:08:04,779 Some examples being medically tailored meals or groceries or produce prescriptions, and 2301 03:08:04,779 --> 03:08:11,189 these are generally targeted towards individuals with or at high risk for a serious health 2302 03:08:11,189 --> 03:08:17,340 condition, often prioritizing patients who also screen positive for food insecurity. 2303 03:08:17,340 --> 03:08:20,290 Let's start with medically tailored meals. 2304 03:08:20,290 --> 03:08:27,100 As a Food Is Medicine intervention, a medically tailored meal referral is coming from the 2305 03:08:27,100 --> 03:08:33,551 health care setting, and then a community based organization is providing a meal tailored 2306 03:08:33,551 --> 03:08:39,479 to the medical needs of the individual patient that is either picked up by the patient or 2307 03:08:39,479 --> 03:08:43,170 their proxy or delivered directly to the patient's home. 2308 03:08:43,170 --> 03:08:47,250 And there's relatively strong evidence to suggest that these interventions can reduce 2309 03:08:47,250 --> 03:08:55,979 hospitalization and readmissions, lower medical costs and improve medication adherence. 2310 03:08:55,979 --> 03:09:00,270 Medically tailored meals are suitable for populations with the highest burden of disability 2311 03:09:00,270 --> 03:09:05,540 and illness because they do not require patients to shop or cook on their own. 2312 03:09:05,540 --> 03:09:12,940 But they come therefore at a relatively high cost, and this creates a challenge for Food Is Medicine interventions. 2313 03:09:12,940 --> 03:09:19,210 It is easiest to demonstrate a return on investment and positive health outcomes for these interventions 2314 03:09:19,210 --> 03:09:25,020 over a short time window, because these patients tend to be the most chronically ill. 2315 03:09:25,020 --> 03:09:30,020 But we don't necessarily want all of our health care investment in Food Is Medicine interventions 2316 03:09:30,020 --> 03:09:34,830 to be targeted toward this very high risk population. 2317 03:09:34,830 --> 03:09:39,939 There's less opportunity for prevention because disease has already occurred and over longer 2318 03:09:39,939 --> 03:09:45,390 time periods, moving upstream and supporting dietary intake earlier in the course of disease 2319 03:09:45,390 --> 03:09:51,149 is likely to have the greatest impact on health outcomes and therefore the greatest return 2320 03:09:51,149 --> 03:09:53,370 on investment. 2321 03:09:53,370 --> 03:09:58,720 Medically tailored groceries differ from meals in that they are raw ingredients that must 2322 03:09:58,720 --> 03:10:00,580 be assembled into meals at home. 2323 03:10:00,580 --> 03:10:05,319 The advantage is they can be provided at a lower cost to the medically tailored meals. 2324 03:10:05,319 --> 03:10:11,100 But of course, they must be provided to a patient population that is able to cook on 2325 03:10:11,100 --> 03:10:12,289 their own. 2326 03:10:12,289 --> 03:10:19,130 These programs are often sometimes...are often implemented by the same organizations that 2327 03:10:19,130 --> 03:10:24,200 provide medically tailored meals as a way to ease patients off of their program, and 2328 03:10:24,200 --> 03:10:28,170 they're sometimes provided as independent programs by food banks. 2329 03:10:28,170 --> 03:10:33,450 There's little evaluation data on medically tailored groceries, but a recent systematic 2330 03:10:33,450 --> 03:10:39,660 review suggested that they can improve food security but have an inconsistent effect on 2331 03:10:39,660 --> 03:10:42,050 other outcomes. 2332 03:10:42,050 --> 03:10:46,430 Produce prescriptions are also considered Food Is Medicine interventions when they're 2333 03:10:46,430 --> 03:10:48,290 tightly linked to health care. 2334 03:10:48,290 --> 03:10:53,420 Produce prescriptions are generally a cash value provided on a paper voucher or an electronic 2335 03:10:53,420 --> 03:10:59,189 benefits transfer card that can be redeemed at a local vendor for fruits and vegetables. 2336 03:10:59,189 --> 03:11:05,010 There are two very large scale programs in the United States; one is the fruit and vegetable 2337 03:11:05,010 --> 03:11:10,899 benefit provided through the WIC program, and the other is the GusNIP stream of federal 2338 03:11:10,899 --> 03:11:15,520 funding through the USDA that you'll learn more about later in this symposium. 2339 03:11:15,520 --> 03:11:20,310 There's lots of heterogeneity in the way these programs look across the country, but there's 2340 03:11:20,310 --> 03:11:25,229 moderate evidence at this point in time that they are able to improve dietary intake and 2341 03:11:25,229 --> 03:11:26,810 food security. 2342 03:11:26,810 --> 03:11:31,439 Modeling studies show that they also have substantial downstream impacts on health outcomes 2343 03:11:31,439 --> 03:11:37,990 and health care costs, and emerging data is helping to support this contention as well. 2344 03:11:37,990 --> 03:11:42,850 These obviously are suitable for populations with the lowest burden of disability and illness, 2345 03:11:42,850 --> 03:11:52,620 and they're often targeted much further upstream towards prevention of the disease. On-site 2346 03:11:52,620 --> 03:11:58,680 Food Is Medicine initiatives are generally developed by the health care system to implement 2347 03:11:58,680 --> 03:11:59,729 on site. 2348 03:11:59,729 --> 03:12:04,290 The lowest catch of these is just educating clinicians and health care staff about the 2349 03:12:04,290 --> 03:12:09,650 importance of screening for food insecurity and sometimes this is accompanied by what 2350 03:12:09,650 --> 03:12:15,210 we call a passive referral or just handing to patients a resource list if they screen 2351 03:12:15,210 --> 03:12:17,540 positive for food insecurity. 2352 03:12:17,540 --> 03:12:22,160 Data suggests, however, that these passive referrals have very little impact on food 2353 03:12:22,160 --> 03:12:25,420 security, dietary intake and downstream health outcomes. 2354 03:12:25,420 --> 03:12:27,010 So, we likely have to do more. 2355 03:12:27,010 --> 03:12:31,950 So, health systems have also explored a number of other onsite options. 2356 03:12:31,950 --> 03:12:37,120 For example, onsite food distribution through a food pantry permanently located at the hospital 2357 03:12:37,120 --> 03:12:44,460 or the clinic that's generally stocked with healthy foods from the food bank, they have 2358 03:12:44,460 --> 03:12:49,779 explored mobile food distributions at the hospital or the clinic, where the food bank 2359 03:12:49,779 --> 03:12:56,540 mobile food truck arrives once a week or once a month to provide food for eligible patients 2360 03:12:56,540 --> 03:13:00,430 and...but the research on these initiatives is still very limited. 2361 03:13:00,430 --> 03:13:06,189 And finally, there are a number of initiatives to increase enrollment assistance into federal 2362 03:13:06,189 --> 03:13:11,630 nutrition programs like SNAP, the Supplemental Nutrition Assistance Program, formerly known 2363 03:13:11,630 --> 03:13:14,140 as the Food Stamps Program. 2364 03:13:14,140 --> 03:13:19,680 This type of initiative is moving upstream towards addressing a social determinant of 2365 03:13:19,680 --> 03:13:25,561 health, but there have been a number of operational challenges identified, but mostly come back 2366 03:13:25,561 --> 03:13:30,720 to the challenges of integrating electronic health records and health systems with the 2367 03:13:30,720 --> 03:13:38,660 systems that are used to assess eligibility for federal nutrition programs. 2368 03:13:38,660 --> 03:13:44,460 Food Is Medicine interventions overall are challenged by short-term funding that requires 2369 03:13:44,460 --> 03:13:47,150 personnel to continue rewriting. 2370 03:13:47,150 --> 03:13:51,689 Food Is Medicine interventions are often implemented with the goal of demonstrating a return on 2371 03:13:51,689 --> 03:13:57,790 investment, which can be very challenging, particularly in the realm of prevention. 2372 03:13:57,790 --> 03:14:02,340 Food is medicine interventions are still often provided for just a very limited amount of 2373 03:14:02,340 --> 03:14:07,760 time, perhaps too short an amount of time to demonstrate health outcomes. 2374 03:14:07,760 --> 03:14:13,100 Referrals into the community are limited by fragmentation and inadequate funding of the 2375 03:14:13,100 --> 03:14:19,479 social safety net and Food Is Medicine interventions are often challenged by changes in priority 2376 03:14:19,479 --> 03:14:21,220 populations by funders. 2377 03:14:21,220 --> 03:14:28,430 So, funders may prioritize diabetes interventions this year and obesity among young adults next 2378 03:14:28,430 --> 03:14:30,430 year as examples. 2379 03:14:30,430 --> 03:14:36,560 We also need to support health systems who are interested in addressing food insecurity 2380 03:14:36,560 --> 03:14:43,770 and moving upstream from addressing an acute social need or an acute need for food today 2381 03:14:43,770 --> 03:14:50,010 towards the social determinant on health of food insecurity, or more specifically, towards 2382 03:14:50,010 --> 03:14:54,960 those fundamental drivers or those root causes of food insecurity in the community. 2383 03:14:54,960 --> 03:14:57,830 This is the next important wave of this research. 2384 03:14:57,830 --> 03:15:03,630 I will leave you with a few good clinical resources. 2385 03:15:03,630 --> 03:15:11,630 And with that, thank you for the opportunity to speak today on this topic. 2386 03:15:15,134 --> 03:15:16,564 DR. FRANCESCA GANY: Hello. 2387 03:15:16,564 --> 03:15:22,479 I'm really happy to be here with you today to speak with you about Food Insecurity Interventions 2388 03:15:22,479 --> 03:15:24,810 to Improve Cancer Outcomes. 2389 03:15:24,810 --> 03:15:31,460 I'm the chief of the Immigrant Health and Cancer Disparities Center at Memorial Sloan Kettering. 2390 03:15:31,460 --> 03:15:38,600 Our mission at the center is to promote health equity for immigrant minority, low SES and 2391 03:15:38,600 --> 03:15:43,920 other underserved communities locally, nationally and globally. 2392 03:15:43,920 --> 03:15:50,410 And we do this work through research, outreach, patient and community engagement, service 2393 03:15:50,410 --> 03:15:54,330 delivery, training, and program and policy development. 2394 03:15:54,330 --> 03:15:59,050 And today, I'm going to speak with you about our food insecurity program. 2395 03:15:59,050 --> 03:16:04,750 We use the social determinants lens in all of our work and food insecurity is such an 2396 03:16:04,750 --> 03:16:08,489 important piece of this. 2397 03:16:08,489 --> 03:16:13,270 So, cancer patients often have increased nutritional needs. 2398 03:16:13,270 --> 03:16:20,699 However, at the same time, their treatment- related costs such as high co-pays, very high 2399 03:16:20,699 --> 03:16:29,010 cost for medications, travel, etc., and income loss contribute to a financial toxicity 2400 03:16:29,010 --> 03:16:37,430 and food insecurity goes hand-in-hand with this financial toxicity of treatment of...cancer treatment. 2401 03:16:37,430 --> 03:16:43,260 Food insecurity leads to poorer functional, emotional, and social well-being and a higher 2402 03:16:43,260 --> 03:16:50,989 risk for depression, and it can lead to care delays, cost-related medication nonadherence, 2403 03:16:50,989 --> 03:16:54,110 and then poorer outcomes. 2404 03:16:54,110 --> 03:17:00,530 So it is vitally important to screen for and address food insecurity in cancer patients. 2405 03:17:00,530 --> 03:17:06,390 in all case...patients, of course, but in cancer patients to potentially improve treatment 2406 03:17:06,390 --> 03:17:12,680 adherence and to decrease outcomes disparities for cancer patients. 2407 03:17:12,680 --> 03:17:19,290 So given the importance of this, we did several studies in New York looking at food insecurity 2408 03:17:19,290 --> 03:17:21,030 in our cancer patients. 2409 03:17:21,030 --> 03:17:27,530 So, when we looked at underserved cancer patients in New York safety net clinics, we found that 2410 03:17:27,530 --> 03:17:35,790 56 percent were food insecure and disturbingly, SNAP recipients were just as likely to be food 2411 03:17:35,790 --> 03:17:42,090 insecure as those not receiving SNAP, which is why it was music to our ears when we heard 2412 03:17:42,090 --> 03:17:48,899 recently that the SNAP benefit levels were going up, and we are hoping that this makes 2413 03:17:48,899 --> 03:17:52,689 a difference and we will certainly be looking into this. 2414 03:17:52,689 --> 03:18:00,359 We also know that food insecurity is a window into other essential needs, such as housing 2415 03:18:00,359 --> 03:18:05,529 and other essential needs that are associated with food security status. 2416 03:18:05,529 --> 03:18:10,040 When we looked at comprehensive cancer centers, we also found high rates of food insecurity 2417 03:18:10,040 --> 03:18:15,290 among the patients between 18 percent to 30 percent were food insecure. 2418 03:18:15,290 --> 03:18:22,210 And this came as quite a surprise to the cancer centers, who had no idea that so many of their 2419 03:18:22,210 --> 03:18:23,560 patients were food insecure. 2420 03:18:23,560 --> 03:18:29,859 Given the large number of food insecure patients, we started to look at food resources. 2421 03:18:29,859 --> 03:18:35,050 So, we did a study of community food pantries, for instance, and we found that they do not 2422 03:18:35,050 --> 03:18:38,109 address cancer patients' needs. 2423 03:18:38,109 --> 03:18:45,120 The hours are wrong considering all of the many appointments people have at the Cancer 2424 03:18:45,120 --> 03:18:46,120 Center. 2425 03:18:46,120 --> 03:18:51,170 The locations, and also the foods were just not tailored for folks who are undergoing 2426 03:18:51,170 --> 03:18:52,550 cancer treatment. 2427 03:18:52,550 --> 03:19:01,140 So, we developed a model of a medically tailored Cancer Clinic-based food pantries co-located in the Cancer Clinics. 2428 03:19:01,140 --> 03:19:07,439 We now have 14 of these located across New York City and they have proven to be immensely 2429 03:19:07,439 --> 03:19:10,720 popular with our patients. 2430 03:19:10,720 --> 03:19:16,189 However, we realize that food pantries are not the only answer to food insecurity in 2431 03:19:16,189 --> 03:19:17,939 our patients. 2432 03:19:17,939 --> 03:19:24,080 In addition to addressing all of the reasons for the financial toxicity of cancer treatment, 2433 03:19:24,080 --> 03:19:30,310 when we think about interventions to directly address the food insecurity pantry is certainly 2434 03:19:30,310 --> 03:19:33,470 one, but others needed to be developed. 2435 03:19:33,470 --> 03:19:39,930 So, we developed a food voucher program that's similar to SNAP in that people get food voucher 2436 03:19:39,930 --> 03:19:45,939 cards that they could use at any grocery stores, bodegas, food shops. 2437 03:19:45,939 --> 03:19:50,450 They're instructed to use it just for food and non-alcoholic beverages, and they get 2438 03:19:50,450 --> 03:19:53,040 a monthly voucher. 2439 03:19:53,040 --> 03:19:58,479 And we also developed an intervention that's basically a commercial grocery delivery service, 2440 03:19:58,479 --> 03:20:03,061 but that only stocks healthful products. 2441 03:20:03,061 --> 03:20:07,810 And these groceries are delivered weekly, and patients choose from a master grocery list. 2442 03:20:07,810 --> 03:20:14,270 All of these interventions are accompanied by nutrition, education, and information for 2443 03:20:14,270 --> 03:20:20,770 the patients, including tips on how to stretch food dollars. 2444 03:20:20,770 --> 03:20:25,840 We took those three interventions, which each seem to have success in their own right, and 2445 03:20:25,840 --> 03:20:32,470 we developed a randomized controlled trial to study the impact of each of these interventions 2446 03:20:32,470 --> 03:20:37,949 on adult cancer patients at four safety net clinics in New York City. 2447 03:20:37,949 --> 03:20:42,890 And was for patients who were starting either chemo, radiation therapy or both and any cancer 2448 03:20:42,890 --> 03:20:45,020 diagnosis or stage. 2449 03:20:45,020 --> 03:20:51,880 And the outcomes we looked at were treatment completion as our primary outcome, appointment, 2450 03:20:51,880 --> 03:20:59,100 attendance, food security status change and quality of life and depression symptoms. 2451 03:20:59,100 --> 03:21:01,630 We had great results. 2452 03:21:01,630 --> 03:21:10,450 We found that the most effective for improving treatment completion was the food voucher, 2453 03:21:10,450 --> 03:21:11,550 plus the pantry arm. 2454 03:21:11,550 --> 03:21:18,689 We saw a 94 percent treatment completion in this group versus 82.5 percent for the home grocery delivery 2455 03:21:18,689 --> 03:21:23,170 and 77.5 percent for the pantry. 2456 03:21:23,170 --> 03:21:29,290 We saw across all arms at 62 or so percent of patients had full appointment, attendance 2457 03:21:29,290 --> 03:21:32,800 of chemotherapy and/or radiation therapy appointments. 2458 03:21:32,800 --> 03:21:36,330 And this was distributed evenly across the arms. 2459 03:21:36,330 --> 03:21:43,270 When we looked at food security status, we saw that there were significant improvements 2460 03:21:43,270 --> 03:21:47,390 in mean USDA food security scores in all three arms. 2461 03:21:47,390 --> 03:21:50,779 It did differ a little bit across the arms. 2462 03:21:50,779 --> 03:21:56,819 The best result was in the pantry arm, followed by the voucher and pantry arm, followed by 2463 03:21:56,819 --> 03:21:58,319 the delivery and pantry. 2464 03:21:58,319 --> 03:22:05,930 We also looked at PHQ-9 and quality of life and found that across all arms, patients had 2465 03:22:05,930 --> 03:22:15,070 fewer depression symptoms at follow up compared to at baseline and for the FACT-G as well, 2466 03:22:15,070 --> 03:22:17,699 scores improved across all three arms. 2467 03:22:17,699 --> 03:22:25,090 The best improvement for both of these were in the delivery plus pantry arm and the pantry 2468 03:22:25,090 --> 03:22:26,090 only arm. 2469 03:22:26,090 --> 03:22:28,550 These were the statistically significant improvements. 2470 03:22:28,550 --> 03:22:35,239 We looked at the voucher arm food choices and found that on average, 77 percent of the funds 2471 03:22:35,239 --> 03:22:41,560 from the vouchers where patients had total choice were spent on healthy food each month. 2472 03:22:41,560 --> 03:22:46,399 Interestingly, patients with limited English proficiency spent more on healthy foods and 2473 03:22:46,399 --> 03:22:51,410 English speaking patients and patients born outside of the U.S. spent more money on healthy 2474 03:22:51,410 --> 03:22:54,850 foods than U.S. born patients. 2475 03:22:54,850 --> 03:23:00,530 But this study suggests that providing patients with supplemental funding for food and with 2476 03:23:00,530 --> 03:23:06,180 nutrition education, patients are going to make great food choices. 2477 03:23:06,180 --> 03:23:11,250 We looked at cost comparisons and found that the pantry only was the least expensive program 2478 03:23:11,250 --> 03:23:16,710 to run, followed by the pantry plus voucher followed by the pantry plus delivery. 2479 03:23:16,710 --> 03:23:21,160 I would be remiss to not speak about the impact of COVID. 2480 03:23:21,160 --> 03:23:26,040 We know how much worse food insecurity has gotten because of COVID. 2481 03:23:26,040 --> 03:23:32,670 So we pivoted our food interventions to make them very COVID-responsive. 2482 03:23:32,670 --> 03:23:40,390 We started to do curbside pick-up of food and more vouchers and many more home deliveries, 2483 03:23:40,390 --> 03:23:42,920 and this made a huge difference for our patients. 2484 03:23:42,920 --> 03:23:48,790 But again, the food insecurity was a really important window into other assistance that 2485 03:23:48,790 --> 03:23:55,569 patients needed, like assistance with navigation for unemployment, SNAP and other public benefits. 2486 03:23:55,569 --> 03:23:57,739 Housing was huge. 2487 03:23:57,739 --> 03:24:02,250 So, this is our work on the very patient-centered level. 2488 03:24:02,250 --> 03:24:07,069 We're also working across the health systems level, the food justice systems level. 2489 03:24:07,069 --> 03:24:11,130 This is, of course, all part of a much bigger ecosystem. 2490 03:24:11,130 --> 03:24:17,540 But thank you so much for giving me the opportunity to speak with you about our work on food interventions 2491 03:24:17,540 --> 03:24:24,330 and the really big impact it had on treatment completion among our cancer patients and on 2492 03:24:24,330 --> 03:24:29,279 quality of life, food security status, and depression symptoms. 2493 03:24:29,279 --> 03:24:35,920 And I want to thank our food team, which has worked so tremendously hard on this program, 2494 03:24:35,920 --> 03:24:41,160 the entire Immigrant Health and Cancer Disparities Center, and also our very generous funders. 2495 03:24:41,160 --> 03:24:44,439 And thank you so much for your time. 2496 03:24:44,439 --> 03:24:57,430 DR. LEONAED EGEDE: Good afternoon, everyone, this is Dr. Leonard Egede. I'm a professor of medicine 2497 03:24:57,430 --> 03:24:59,029 at the Medical College of Wisconsin. 2498 03:24:59,029 --> 03:25:05,290 I'm also the Director of the Center for Advancing Population Science and the director of the 2499 03:25:05,290 --> 03:25:10,460 Division Chief of the Division of General Internal Medicine in Wisconsin. 2500 03:25:10,460 --> 03:25:16,870 I'm here today to talk about interventions to address type 2 diabetes among African-Americans 2501 03:25:16,870 --> 03:25:19,109 experiencing food insecurity. 2502 03:25:19,109 --> 03:25:26,510 And one of the things we've tried to do as part of our work is to really focus on the 2503 03:25:26,510 --> 03:25:28,689 lived experience of individuals as we develop our interventions. 2504 03:25:28,689 --> 03:25:34,460 So, I'm going to share a study that we did that really shaped on how we actually do research 2505 03:25:34,460 --> 03:25:39,080 right now in food insecure African-Americans and the strategy you need experience of food 2506 03:25:39,080 --> 03:25:42,160 insecure African African-Americans with type 2 diabetes living inner city. 2507 03:25:42,160 --> 03:25:47,949 And this was in focus groups that we did. It was a study that was to get insight from the 2508 03:25:47,949 --> 03:25:52,240 perspective of food insecure African-Americans living an inner city environment regarding 2509 03:25:52,240 --> 03:25:54,899 important diabetes intervention strategies and components. 2510 03:25:54,899 --> 03:26:00,149 With the two focus groups with about 16 individuals who are food insecure who also had type 2 2511 03:26:00,149 --> 03:26:01,149 diabetes. 2512 03:26:01,149 --> 03:26:03,530 We use the grounded theory approach. 2513 03:26:03,530 --> 03:26:07,739 Questions were asked as to what challenges and barriers to managing diabetes within the context of 2514 03:26:07,739 --> 03:26:13,449 food insecurity and the facilities, or resources that help participants improve diabetes management? 2515 03:26:13,449 --> 03:26:19,120 And what I have here is a slide that goes through what the community and the individuals 2516 03:26:19,120 --> 03:26:23,229 identified as useful, valuable interventions that will really help them. 2517 03:26:23,229 --> 03:26:27,261 So, the first was group-based education, and in that, you wanted to see groups of 10 to 2518 03:26:27,261 --> 03:26:31,620 12 people where they could discuss problems and challenges, where they could have discussions 2519 03:26:31,620 --> 03:26:32,620 about medication management. 2520 03:26:32,620 --> 03:26:34,979 They thought a mixed sex group would be helpful. 2521 03:26:34,979 --> 03:26:39,100 And that the health care facility that should be part of that group and it didn't matter 2522 03:26:39,100 --> 03:26:43,390 what the risk of the individual was, as long as it was sensitive to the needs. 2523 03:26:43,390 --> 03:26:48,430 The second was peer support, where individuals living with the disease could actually serve 2524 03:26:48,430 --> 03:26:54,560 as peer mentors and where the mentors would have mastered diabetes and lived with it for a while, where 2525 03:26:54,560 --> 03:26:59,390 there were opportunities for peers to share experiences, challenges, and successes for 2526 03:26:59,390 --> 03:27:00,390 strategy. 2527 03:27:00,390 --> 03:27:04,540 The third was access to community resources on programs where they actually had access 2528 03:27:04,540 --> 03:27:09,960 to vouchers to farmers' markets or grocery stores, stock boxes, information about how 2529 03:27:09,960 --> 03:27:14,050 to use and cook the food in the boxes, recipe and cookbooks. 2530 03:27:14,050 --> 03:27:17,689 And the third…a 1-to-2 month frequency was optimal. 2531 03:27:17,689 --> 03:27:21,630 frequency was optimal. 2532 03:27:21,630 --> 03:27:26,630 talk openly about stress, having a social worker, a clinical person to provide counseling 2533 03:27:26,630 --> 03:27:27,630 on stress. 2534 03:27:27,630 --> 03:27:32,330 And a fifth category of interventions with faith-based programs where it was positive 2535 03:27:32,330 --> 03:27:35,890 messaging, prayer, and use of scripture verses, motivational messages. 2536 03:27:35,890 --> 03:27:41,109 So we have used this as a way to actually develop and test our interventions. 2537 03:27:41,109 --> 03:27:45,729 But what we also find as part of the focus group was that we actually realized that stigma 2538 03:27:45,729 --> 03:27:47,560 was a big issue. 2539 03:27:47,560 --> 03:27:53,029 And so, the current USDA food insecurity measure doesn't really account for some of these issues. 2540 03:27:53,029 --> 03:27:55,630 So, I want to share with you a food insecurity risk tool that we've developed that allows 2541 03:27:55,630 --> 03:28:00,729 us, to really hone in on the needs of the community. 2542 03:28:00,729 --> 03:28:06,109 So the current USDA measurements does not account for contextual factors and the multidimensional 2543 03:28:06,109 --> 03:28:10,600 risk for food insecurity that's associated with the underlying issue of poverty. 2544 03:28:10,600 --> 03:28:12,960 The poverty drives a lot of what we see. 2545 03:28:12,960 --> 03:28:17,060 It does not account for stigma that's associated with food insecurity, and it also does not 2546 03:28:17,060 --> 03:28:21,159 assess food and nutrition security defined particularly as supported by an environment 2547 03:28:21,159 --> 03:28:26,689 of adequate sanitation, health services and care wanted for a healthy and active life. 2548 03:28:26,689 --> 03:28:31,840 Then also, we've also found that measuring food security apart from nutritional security, 2549 03:28:31,840 --> 03:28:36,270 creates gaps in understanding and addressing the problems typically associated with food 2550 03:28:36,270 --> 03:28:38,870 insecurity, especially for individuals with chronic disease. 2551 03:28:38,870 --> 03:28:44,840 So we've created this tool—it has about seven items—and there's a yes or no items, which 2552 03:28:44,840 --> 03:28:48,779 a yes been a score of one and no been a score of zero. 2553 03:28:48,779 --> 03:28:53,569 The first item is: Would your annual household income be described as this at $25,000? 2554 03:28:53,569 --> 03:28:58,510 Two: Did you ever go without food, clothing or housing because she needed the money for medical 2555 03:28:58,510 --> 03:28:59,510 care? 2556 03:28:59,510 --> 03:29:02,860 Three: In the past 12 months, would you say you were worried or stressed about having 2557 03:29:02,860 --> 03:29:05,400 enough money to pay your rent or mortgage? 2558 03:29:05,400 --> 03:29:09,160 Four: In the past 12 months, would you say you were worried or stressed about having 2559 03:29:09,160 --> 03:29:10,870 enough money to buy nutritious meals? 2560 03:29:10,870 --> 03:29:15,351 Five: Was the time in the past 12 months when you needed to see a doctor but could not because 2561 03:29:15,351 --> 03:29:16,810 of costs? 2562 03:29:16,810 --> 03:29:19,069 Six: Was there a time in the past 12 months when you did not take your medication as prescribed 2563 03:29:19,069 --> 03:29:20,069 because of cost? 2564 03:29:20,069 --> 03:29:22,880 And seven: Do you consider your neighborhood to be safe from crime? 2565 03:29:22,880 --> 03:29:33,229 And then so, we scored this on a scale of zero to seven with a score of two or more being indicative 2566 03:29:33,229 --> 03:29:34,580 of food insecurity. 2567 03:29:34,580 --> 03:29:38,890 We've tested this in multiple models right now, and what we have here is an analysis 2568 03:29:38,890 --> 03:29:44,180 that we did looking at the food insecurity risk tool, as a predictor of food insecurity using 2569 03:29:44,180 --> 03:29:45,180 the USDA tool. 2570 03:29:45,180 --> 03:29:52,020 And in this case, if you are two or more... if you score two or more overall you had almost 2571 03:29:52,020 --> 03:29:55,380 4.5 times the risk of having food insecurity. 2572 03:29:55,380 --> 03:30:01,320 If you score three questions positive, it's 13 times increased risk. 2573 03:30:01,320 --> 03:30:06,479 If you are four or more, you are almost at a 54 increased risk of food insecurity using the 2574 03:30:06,479 --> 03:30:09,690 USDA tool as the benchmark. 2575 03:30:09,690 --> 03:30:16,140 We also then looked at this in the diabetes population, the African-American only population, 2576 03:30:16,140 --> 03:30:17,870 African-American and diabetes population. 2577 03:30:17,870 --> 03:30:22,279 And the results are very consistent in terms of what that means. 2578 03:30:22,279 --> 03:30:27,090 So, a score of two or more really helps you identify individuals who are at high risk 2579 03:30:27,090 --> 03:30:31,620 for food insecurity, but does not put them at a position where they actually have to 2580 03:30:31,620 --> 03:30:36,540 declare specifically, you know, these types of issues they are highly, but also minimizes, 2581 03:30:36,540 --> 03:30:38,600 the stigma associated with insecurity. 2582 03:30:38,600 --> 03:30:44,830 And so we are now doing this study right now that we're calling lowering the impact of 2583 03:30:44,830 --> 03:30:49,939 food insecurity in African-American adults with type 2 diabetes, according to LIFT-DM study. 2584 03:30:49,939 --> 03:30:55,860 And this study was funded by NIMHD, it's a five-year NIH R01. 2585 03:30:55,860 --> 03:31:00,319 And the background is that there are currently no randomized trials that indicate whether 2586 03:31:00,319 --> 03:31:03,790 food supplementation is beneficial to improving glycemic control. 2587 03:31:03,790 --> 03:31:07,430 We know that food supplementation is useful, but it does...there's really no study on what 2588 03:31:07,430 --> 03:31:12,430 does that do for a food insecure individuals and their diabetes control. 2589 03:31:12,430 --> 03:31:17,870 So, in the LIFT-DM maximizes resources through a factorial design to test a series of essential 2590 03:31:17,870 --> 03:31:23,011 questions for informing cost-effective, efficacious strategies to improve health for food insecure 2591 03:31:23,011 --> 03:31:24,440 African Americans with diabetes. 2592 03:31:24,440 --> 03:31:25,859 We have three questions: 2593 03:31:25,859 --> 03:31:30,560 Does food supplementation compare with diabetes education, improve that outcomes beyond diabetes 2594 03:31:30,560 --> 03:31:31,560 education alone? 2595 03:31:31,560 --> 03:31:34,840 Two: What type of food supplementation is most effective? 2596 03:31:34,840 --> 03:31:40,340 And three: What combination of food supplementation and diabetes education is most effective in 2597 03:31:40,340 --> 03:31:41,570 lowering glycemic control? 2598 03:31:41,570 --> 03:31:45,939 So, you need two-by-two factorial design, and the idea is one group gets usual care with 2599 03:31:45,939 --> 03:31:47,699 just diabetes education. 2600 03:31:47,699 --> 03:31:54,120 Second group gets a food supplementation via vouchers, and the third group gets food supplementation 2601 03:31:54,120 --> 03:31:59,380 via stock boxes, and the fourth group gets the combination of vouchers and stock boxes. 2602 03:31:59,380 --> 03:32:02,080 And we're going to follow them for 12 months to see if their diabetes control is better 2603 03:32:02,080 --> 03:32:03,080 and their quality of life is better. 2604 03:32:03,080 --> 03:32:08,800 And this would give us really important information about food supplementation for 2605 03:32:08,800 --> 03:32:11,770 people with diabetes, and also for those with chronic disease. 2606 03:32:11,770 --> 03:32:16,680 And so, in conclusion, what are the future directions that this field needs to go to? 2607 03:32:16,680 --> 03:32:19,580 One is how do we address stigma as attached to food insecurity? 2608 03:32:19,580 --> 03:32:25,300 Two is, what kind of tailored interventions do we need to build that builds upon on the lived 2609 03:32:25,300 --> 03:32:27,100 experiences of African-Americans in an inner city environment? 2610 03:32:27,100 --> 03:32:37,021 The third area is the idea of using a food insecurity risk tool, which allows us to capture 2611 03:32:37,021 --> 03:32:45,580 individuals who are food insecure but does not allow them to feel stigmatized as a result. 2612 03:32:45,580 --> 03:32:49,750 And then finally, addressing food insecurity as a poverty issue, as opposed to an isolated 2613 03:32:49,750 --> 03:32:50,750 problem. 2614 03:32:50,750 --> 03:32:54,380 We believe that interventions that focus on structural racism and policies that perpetuate 2615 03:32:54,380 --> 03:32:59,040 poverty are needed to really address this issue, and novel interventions that focus 2616 03:32:59,040 --> 03:33:02,950 on alleviating poverty as a strategy to alleviating food security are needed. 2617 03:33:02,950 --> 03:33:06,510 So overall, we think this is going to get us in the right direction as we begin to do 2618 03:33:06,510 --> 03:33:14,020 more work focused on really treating poverty as underlying framework for food insecurity. 2619 03:33:14,020 --> 03:33:18,100 Thank you. 2620 03:33:18,100 --> 03:33:27,790 DR. MARLENE SHWARTZ: Thanks, everyone, for those wonderful presentations. 2621 03:33:27,790 --> 03:33:31,380 We have some questions. 2622 03:33:31,380 --> 03:33:40,359 The first one is for Dr. Amy Yaroch, and it's about efforts to evaluate the impact of deafness 2623 03:33:40,359 --> 03:33:42,500 incentive programs on health outcomes. 2624 03:33:42,500 --> 03:33:45,880 DR. AMY YAROCH: Yeah, that's a great question. 2625 03:33:45,880 --> 03:33:47,000 Thanks, Marlene. 2626 03:33:47,000 --> 03:33:53,239 So, GusNIP grantees both nutrition incentive and produce prescription programs are assessing 2627 03:33:53,239 --> 03:33:59,280 self-reported health status among their participants, but for produce prescription programs, 2628 03:33:59,280 --> 03:34:04,479 some of the grantees are clinical in nature and so...or they're partnering with clinical 2629 03:34:04,479 --> 03:34:08,220 groups and linking to electronic health records. 2630 03:34:08,220 --> 03:34:15,439 And so, they are...actually are assessing clinical markers like A1c, BMI, and other health outcomes. 2631 03:34:15,439 --> 03:34:18,400 DR. MARLENE SCHWARTZ: Great, thank you. 2632 03:34:18,400 --> 03:34:27,540 So, there are a couple of questions for Dr. Lisa Harnack about the work that you presented. 2633 03:34:27,540 --> 03:34:32,340 And one of them is about whether the use of restrictions might lead to demoralization 2634 03:34:32,340 --> 03:34:36,779 among those who are in need of assistance. 2635 03:34:36,779 --> 03:34:43,550 And then sort of relatedly, what were the perspectives of SNAP participants in the paired 2636 03:34:43,550 --> 03:34:44,550 intervention? 2637 03:34:44,550 --> 03:34:46,109 DR. LISA HARNACK: Right. 2638 03:34:46,109 --> 03:34:47,850 So really good questions. 2639 03:34:47,850 --> 03:34:52,859 You know, when we asked people who had been receiving benefits with the restrictions in 2640 03:34:52,859 --> 03:34:58,990 place, you sort of saw what I presented in that most either had a positive reaction or 2641 03:34:58,990 --> 03:35:00,720 a neutral feeling about it. 2642 03:35:00,720 --> 03:35:07,460 With the positive reactions it was often people saying, you know, "It's good for me, it's, 2643 03:35:07,460 --> 03:35:12,550 I want to eat healthier and this is, you know, nudging me or helping me with 2644 03:35:12,550 --> 03:35:13,550 that." 2645 03:35:13,550 --> 03:35:14,550 So, it didn't seem to be demoralizing. 2646 03:35:14,550 --> 03:35:21,710 It seemed to, you know, although for the small percent who are opposed to it, they could 2647 03:35:21,710 --> 03:35:22,710 feel demoralizing. 2648 03:35:22,710 --> 03:35:27,290 In particular, we heard people say, "Well, this means I can't get, you know, a cake for 2649 03:35:27,290 --> 03:35:30,320 my granddaughter's birthday party" or something like that. 2650 03:35:30,320 --> 03:35:36,470 Like, this sort of, no sweets...would...might be too extreme for some 2651 03:35:36,470 --> 03:35:38,560 people. 2652 03:35:38,560 --> 03:35:43,489 And then when we looked at people who were paired with the restrictions and the incentives 2653 03:35:43,489 --> 03:35:47,779 and the restrictions only they had similar levels of support for restrictions. 2654 03:35:47,779 --> 03:35:52,609 It didn't look like the incentives, paired with that changed that outlook. 2655 03:35:52,609 --> 03:35:57,410 When we asked specifically about the incentives uniformly, everybody loves the incentives. 2656 03:35:57,410 --> 03:36:02,630 You know, this is a really great thing from the participant perspective to be getting 2657 03:36:02,630 --> 03:36:04,689 an incentive for buying fruits and vegetables. 2658 03:36:04,689 --> 03:36:07,449 DR. MARLENE SCHWARTZ: Thank you. 2659 03:36:07,449 --> 03:36:14,439 So, there's another question about whether... and I think this is correct. 2660 03:36:14,439 --> 03:36:19,000 There wasn't an incentive only group in the study. Is that...is that right? 2661 03:36:19,000 --> 03:36:20,650 And the question is why? 2662 03:36:20,650 --> 03:36:25,950 DR. LISA HARNACK: In the first study there was and for the ease of convenience of presentation, 2663 03:36:25,950 --> 03:36:26,950 I didn't show the results. 2664 03:36:26,950 --> 03:36:30,850 But in that first study, there was an incentive only group. 2665 03:36:30,850 --> 03:36:39,870 And the effect on diet was increasing fruit intake and no other effects on diet quality. 2666 03:36:39,870 --> 03:36:46,670 In the second study, the funding organizations said, "You know, we kind of already know what 2667 03:36:46,670 --> 03:36:51,790 incentives alone do between the healthy incentive pilot study and your previous study. 2668 03:36:51,790 --> 03:36:56,650 Please focus on restrictions alone and restrictions paired with incentives." 2669 03:36:56,650 --> 03:36:59,029 So that's what we did in the second study. 2670 03:36:59,029 --> 03:37:00,439 DR. MARLENE SCHWARTZ: Great. Thank you. 2671 03:37:00,439 --> 03:37:05,920 So, a couple of questions for Hilary Seligman. 2672 03:37:05,920 --> 03:37:13,100 One: Can you talk more about insurance coverage for Food Is Medicine interventions? 2673 03:37:13,100 --> 03:37:16,550 And can you get that under Medicaid or Medicare? 2674 03:37:16,550 --> 03:37:22,170 And then also, can you talk about any Food is Medicine interventions provided by RDs 2675 03:37:22,170 --> 03:37:23,380 in clinical settings? 2676 03:37:23,380 --> 03:37:28,640 DR. HILLARY SELIGMAN: There are great questions, let me start with the insurance coverage. 2677 03:37:28,640 --> 03:37:33,840 I would say that insurance coverage for food is medicine interventions is very patchwork 2678 03:37:33,840 --> 03:37:35,699 and spotty right now. 2679 03:37:35,699 --> 03:37:43,560 There are states that have applied for Medicaid waivers to cover Food is Medicine interventions. 2680 03:37:43,560 --> 03:37:48,620 And so, there is some opportunity for a coverage depending on your area. 2681 03:37:48,620 --> 03:37:56,030 And there is some consideration of making these benefits more federally available but 2682 03:37:56,030 --> 03:37:57,890 that has not happened yet. 2683 03:37:57,890 --> 03:38:03,010 There are also programs within private insurance insurance companies to cover programs such 2684 03:38:03,010 --> 03:38:04,170 as medically tailored meals. 2685 03:38:04,170 --> 03:38:12,359 As far as RDs go, I would say RD involvement in this space has been extremely important 2686 03:38:12,359 --> 03:38:15,949 in their participation and involvement has come in two ways. 2687 03:38:15,949 --> 03:38:22,420 The first is most of these food as medicine interventions have a nutrition education component 2688 03:38:22,420 --> 03:38:23,420 to them. 2689 03:38:23,420 --> 03:38:27,460 I was particularly focusing on the provision of food, but I think it's really important 2690 03:38:27,460 --> 03:38:34,430 we call out the provision of education as well, and RDs are usually driving that component. 2691 03:38:34,430 --> 03:38:37,280 And the second way is by being the clinical champion. 2692 03:38:37,280 --> 03:38:41,840 All of these Food Is Medicine interventions can only get off the ground with a really 2693 03:38:41,840 --> 03:38:47,730 involved clinical champion, and RDs are often playing that role as well. 2694 03:38:47,730 --> 03:38:49,620 DR. MARLENE SCHWARTZ: Great, thank you. 2695 03:38:49,620 --> 03:38:55,290 So, a question for Dr. Caitlin Caspi, you talked about toward the end of your presentation 2696 03:38:55,290 --> 03:39:00,250 this idea of layering different policies to look at impact. 2697 03:39:00,250 --> 03:39:04,540 What types of local policies do you think we should be thinking about that would actually 2698 03:39:04,540 --> 03:39:08,180 pair well with a minimum wage policy and amplify in particular, the health benefits? 2699 03:39:08,180 --> 03:39:10,430 DR. CAITLIN CASPI: Yeah, thanks for that question. 2700 03:39:10,430 --> 03:39:20,560 So, we're thinking about this a lot in our wage study because Minneapolis, as a city 2701 03:39:20,560 --> 03:39:24,699 that...who had that with a city council that's likely to pass a minimum wage ordinance, it's 2702 03:39:24,699 --> 03:39:32,500 also going to be the type of city that's considering a number of other policies that could, again, 2703 03:39:32,500 --> 03:39:38,250 it could enhance the effects of the policy. 2704 03:39:38,250 --> 03:39:45,600 So, for example, they also passed a paid sick leave bill ordinance around the same time. 2705 03:39:45,600 --> 03:39:52,859 There's been a lot of discussion by City Council around housing and single family zoning, affordable 2706 03:39:52,859 --> 03:40:00,580 housing in the city, as well as a lot of discussion and reckoning around policing policies. 2707 03:40:00,580 --> 03:40:07,569 And so, I think that when we're thinking about sort of local policies that can address sort 2708 03:40:07,569 --> 03:40:14,290 of economic stability, it can also include affordable housing and the ways in which we 2709 03:40:14,290 --> 03:40:18,950 live in and increase how safe we feel in our communities. 2710 03:40:18,950 --> 03:40:24,620 And so I want to say that we're thinking about this because in contrast, the same types of 2711 03:40:24,620 --> 03:40:30,261 cities that are not considering minimum wage policies are also going to be policies that 2712 03:40:30,261 --> 03:40:38,970 then are not considering policies like potentially housing policies or paid sick leave. 2713 03:40:38,970 --> 03:40:41,910 And it can potentially increase the geographic disparities 2714 03:40:41,910 --> 03:40:48,270 when you have this sort of layering effect of local policies. 2715 03:40:48,270 --> 03:40:54,300 And what that speaks to is the importance of federal policies and those that can sort 2716 03:40:54,300 --> 03:41:01,330 of cover a large swath of the population in order to not increase the disparities. 2717 03:41:01,330 --> 03:41:03,040 DR. MARLENE SCHWARTZ: Hey, thank you. 2718 03:41:03,040 --> 03:41:11,060 So, a couple of questions for Dr. Francesca Gany, one of them is: Did you measure malnutrition 2719 03:41:11,060 --> 03:41:15,330 improvements in the cancer patients who you're working with that, who were participating 2720 03:41:15,330 --> 03:41:18,200 in the different intervention arms? 2721 03:41:18,200 --> 03:41:23,229 And then the second question is a follow up to your observation about that the food that 2722 03:41:23,229 --> 03:41:29,409 was in the food pantries and why you decided to create this targeted...specialized food 2723 03:41:29,409 --> 03:41:30,409 pantry. 2724 03:41:30,409 --> 03:41:35,840 Do you think that a food pantry that was in general trying to really focus on providing 2725 03:41:35,840 --> 03:41:41,500 healthy foods that meet the dietary guidelines would be different than what the pantry that 2726 03:41:41,500 --> 03:41:43,359 you guys created? 2727 03:41:43,359 --> 03:41:47,840 Or do you think that that would sort of meet the needs of most cancer patients? 2728 03:41:47,840 --> 03:41:49,399 DR. FRANCESCA GANY: Yeah, great. 2729 03:41:49,399 --> 03:41:58,120 So, in terms of the first question, we are studying nutrition indicators and it seems 2730 03:41:58,120 --> 03:42:03,029 like across all three arms we saw tremendous improvement, but we're still analyzing that 2731 03:42:03,029 --> 03:42:04,029 data. 2732 03:42:04,029 --> 03:42:12,430 But it looks like all three forms were important in terms of looking at indicators of poor 2733 03:42:12,430 --> 03:42:14,710 nutrition, etc. 2734 03:42:14,710 --> 03:42:20,909 In terms of just what a great, balanced diet with whole foods and fruits and vegetables, 2735 03:42:20,909 --> 03:42:28,080 and which would be healthy for everyone, that would certainly be fabulous for the cancer 2736 03:42:28,080 --> 03:42:29,080 patients. 2737 03:42:29,080 --> 03:42:34,490 The only difference is we have a little bit more leeway in terms of a couple of things. 2738 03:42:34,490 --> 03:42:40,720 One is, when people have cancer related symptoms and need a little bit more choice and a little 2739 03:42:40,720 --> 03:42:46,960 bit more tweaking and tailoring, we're able to sort of swoop on in and help that way. 2740 03:42:46,960 --> 03:42:49,930 I mean, that's really the biggest difference. 2741 03:42:49,930 --> 03:42:56,840 And the other thing is, if folks have some mechanical issues secondary, eating secondary 2742 03:42:56,840 --> 03:43:02,520 to their cancers, then we're able to help in that regard too and really tailor it that 2743 03:43:02,520 --> 03:43:03,520 way. 2744 03:43:03,520 --> 03:43:12,229 So generally, healthy diet would be great for most of our patients, but we do need to 2745 03:43:12,229 --> 03:43:14,340 tweak it in some additional ways. 2746 03:43:14,340 --> 03:43:21,699 DR. MARLENE SCHWARTZ: That's really, really helpful and really interesting to sort of appreciate the 2747 03:43:21,699 --> 03:43:22,699 nuance there. 2748 03:43:22,699 --> 03:43:28,690 Dr. Egede, there is a question for you about, if you have suggested survey tools that can 2749 03:43:28,690 --> 03:43:34,380 be used to measure and better understand the stigma around food insecurity? 2750 03:43:34,380 --> 03:43:37,500 DR. LEONAED EGEDE: Yes. So, can you hear me? 2751 03:43:37,500 --> 03:43:38,500 DR. MARLENE SCHWARTZ: Yeah. 2752 03:43:38,500 --> 03:43:41,680 DR. LEONAED EGEDE: So, I think this is something we've actually been working on for a while 2753 03:43:41,680 --> 03:43:42,680 now. 2754 03:43:42,680 --> 03:43:48,330 So there are a couple of tools that are really focused on food pantry stigma. 2755 03:43:48,330 --> 03:43:52,560 So going to a food pantry but there's nothing out there that really measures stigma across 2756 03:43:52,560 --> 03:43:53,560 the board. 2757 03:43:53,560 --> 03:43:57,399 So we are actually developing a tool right now and painlessly destination one of our 2758 03:43:57,399 --> 03:43:58,399 studies. 2759 03:43:58,399 --> 03:44:02,310 We should be able to have something that's valid and reliable, probably by the end of 2760 03:44:02,310 --> 03:44:03,310 the year. 2761 03:44:03,310 --> 03:44:07,680 But there is nothing right that can actually measures that level of stigma. 2762 03:44:07,680 --> 03:44:12,319 DR. MARLENE SCHWARTZ: Great, and then a second question just came in for you as well. 2763 03:44:12,319 --> 03:44:16,670 You talked about food supplementation intervention along with nutrition education for diabetes, 2764 03:44:16,670 --> 03:44:23,550 and the question is, is this whole food through pantries or a targeted prepared meals delivered 2765 03:44:23,550 --> 03:44:25,340 during the study time? 2766 03:44:25,340 --> 03:44:30,110 And also, did you take cultural component into consideration so that the culture of 2767 03:44:30,110 --> 03:44:31,140 the people you were working with? 2768 03:44:31,140 --> 03:44:33,420 DR. LEONAED EGEDE: Yes, I think this is one of the challenges. 2769 03:44:33,420 --> 03:44:37,000 I'm sure there was this work your how challenging this is. 2770 03:44:37,000 --> 03:44:39,410 So we partnered with Hunger Task Force. 2771 03:44:39,410 --> 03:44:45,739 And so we provide vouchers, we actually provide and you can actually go to the mobile van 2772 03:44:45,739 --> 03:44:47,062 and actually pick up items. 2773 03:44:47,062 --> 03:44:49,859 And we actually suggest items you can pick up. 2774 03:44:49,859 --> 03:44:55,689 The stock boxes actually developed in such a way that we try to get things that are relatively 2775 03:44:55,689 --> 03:45:01,850 culturally appropriate, but that's very limited ability to modify the stock boxes directly. 2776 03:45:01,850 --> 03:45:08,080 So in terms of, you know, the issue about the vouchers and stock boxes there are relatively 2777 03:45:08,080 --> 03:45:10,909 kind in terms of stock boxes. 2778 03:45:10,909 --> 03:45:15,620 The vouchers, you have a lot of options in terms of what you can pick. 2779 03:45:15,620 --> 03:45:19,040 The combination is a combination of both, and that actually came from focus groups where 2780 03:45:19,040 --> 03:45:20,420 people asked "Can we have both?" 2781 03:45:20,420 --> 03:45:25,290 In terms of the culture of tailoring the items, what we are finding for focus groups is not 2782 03:45:25,290 --> 03:45:28,830 just the food, is also have to prepare the meals. 2783 03:45:28,830 --> 03:45:33,630 So, you know in addition to items that got you want people asking questions about what 2784 03:45:33,630 --> 03:45:37,860 should you know, I need to be familiar with this food, I need some idea of how to actually 2785 03:45:37,860 --> 03:45:38,860 prepare some of those meals. 2786 03:45:38,860 --> 03:45:43,100 So, we're working on how to modify some of the structures going forward. 2787 03:45:43,100 --> 03:45:46,135 But the key thing is that when you create a truly culturally two boxers, there are going 2788 03:45:46,135 --> 03:45:52,069 to be very expensive because you're actually going to have to look into not just a culture 2789 03:45:52,069 --> 03:45:53,270 where individual preferences. 2790 03:45:53,270 --> 03:45:56,850 DR. MARLENE SCHWARTZ: Right, right. Thank you. 2791 03:45:56,850 --> 03:46:04,840 So the next question wasn't directed towards any individual person, but it was about whether 2792 03:46:04,840 --> 03:46:10,390 any of you know of data regarding interventions that are tailored to the elderly or seniors 2793 03:46:10,390 --> 03:46:13,140 65 and over? 2794 03:46:13,140 --> 03:46:25,779 DR. LEONAED EGEDE: I think there are pilot studies done mostly pilot studies that we've come across. 2795 03:46:25,779 --> 03:46:31,560 I'm not aware and I could be wrong, but I'm not aware of any large randomized trials where 2796 03:46:31,560 --> 03:46:36,620 they've actually focused on the elderly, where they've actually done special studies, especially 2797 03:46:36,620 --> 03:46:40,050 to the elderly, but others may have other ideas. 2798 03:46:40,050 --> 03:46:44,950 I'll just write two potential avenues to look into. 2799 03:46:44,950 --> 03:46:50,020 One is any of the programs that are implemented through Medicare are going to obviously be 2800 03:46:50,020 --> 03:46:51,310 that age group. 2801 03:46:51,310 --> 03:46:58,350 But also there was a really lovely study done on SNAP enrollment, outreach and assistance 2802 03:46:58,350 --> 03:47:05,439 and referrals to community benefits among dual eligibles at an organization called Benefits 2803 03:47:05,439 --> 03:47:07,220 Data Trust. 2804 03:47:07,220 --> 03:47:13,150 And they were able to show really, positive impacts on food insecurity rates with the 2805 03:47:13,150 --> 03:47:15,580 work that they did. 2806 03:47:15,580 --> 03:47:20,609 So I would also look up the work done by Benefits Data Trust. 2807 03:47:20,609 --> 03:47:22,540 DR. MARLENE SCHWARTZ: Right, thank you. 2808 03:47:22,540 --> 03:47:28,210 So two people actually wrote in very similar questions, and this is a big question, I think 2809 03:47:28,210 --> 03:47:34,780 directed to everyone, which is how sustainability, environmental food system sustainability fits 2810 03:47:34,780 --> 03:47:40,739 in with the interventions you presented or with your plans for future programs and research. 2811 03:47:40,739 --> 03:47:45,170 So I'll let whoever would like to take a crack at that one first. 2812 03:47:45,170 --> 03:47:46,750 Go ahead. 2813 03:47:46,750 --> 03:47:56,989 DR. FRANCESCA GANY: I can jump in with two quick comments, the first is that diets that are high in fruit 2814 03:47:56,989 --> 03:48:05,640 and vegetables are less burdensome to the environment than diet high in meats. 2815 03:48:05,640 --> 03:48:11,060 And so almost all of the interventions we've discussed today really encourage people to 2816 03:48:11,060 --> 03:48:15,350 adopt a plant forward diet, which is positive for the environment. 2817 03:48:15,350 --> 03:48:21,180 The second thing is that a lot of these interventions also encourage people to buy foods from smaller 2818 03:48:21,180 --> 03:48:27,270 grocery stores and farmer's markets, which enhance local food production and purchasing. 2819 03:48:27,270 --> 03:48:32,000 And to the extent that that also supports environmental sustainability, I think these 2820 03:48:32,000 --> 03:48:36,840 programs are really heavily in alignment with climate change efforts. 2821 03:48:36,840 --> 03:48:38,520 And I'll just add on him to say USDA 2822 03:48:38,520 --> 03:48:41,290 step was made a permanent part of the Farm Bill. 2823 03:48:41,290 --> 03:48:45,170 And so if we can show positive outcomes like increased fruit and vegetable consumption 2824 03:48:45,170 --> 03:48:50,920 and some of these health outcomes, then we can really help to continue to make the case 2825 03:48:50,920 --> 03:48:53,102 for these programs and sustainability of them. 2826 03:48:53,102 --> 03:48:58,220 And again, fruits and vegetables all about incentives. So... 2827 03:48:58,220 --> 03:49:00,450 DR. MARLENE SCHWARTZ: Alright, thank you. 2828 03:49:00,450 --> 03:49:04,359 OK, well, we are at the end of our time. It's been great. 2829 03:49:04,359 --> 03:49:09,750 I want to thank everyone audience for your questions and our panelists for sharing their 2830 03:49:09,750 --> 03:49:12,400 innovative intervention work. 2831 03:49:12,400 --> 03:49:18,060 Next, we are going to move into our networking break so you can engage with your fellow attendees 2832 03:49:18,060 --> 03:49:20,220 on the topics we just discussed. 2833 03:49:20,220 --> 03:49:25,490 And there you'll find a moderated chat discussion to share your takeaways and highlights from 2834 03:49:25,490 --> 03:49:26,990 these innovative interventions. 2835 03:49:26,990 --> 03:49:32,750 Please participate in the networking lounge until 4:55 p.m., and at that time, we will 2836 03:49:32,750 --> 03:49:38,250 begin our final presentation of the day, which is gaps and opportunities to address food 2837 03:49:38,250 --> 03:49:43,340 insecurity and promote racial equity in the context of structural and social determinants 2838 03:49:43,340 --> 03:49:44,340 of health. 2839 03:49:44,340 --> 03:49:45,970 Thank you, everyone. 2840 03:49:45,970 --> 03:49:47,250 Thank you. 2841 03:49:47,250 --> 03:49:50,460 DR. ANGELA ODOMS-YOUNG: Welcome back, everyone. 2842 03:49:50,460 --> 03:49:55,060 Hopefully, you enjoyed the discussion during the networking session. 2843 03:49:55,060 --> 03:50:02,069 I have the pleasure of introducing our final speaker is going to talk about gaps and opportunities 2844 03:50:02,069 --> 03:50:07,370 to address food insecurity and promotion of racial equity in the context of structural 2845 03:50:07,370 --> 03:50:09,550 and social determinants. 2846 03:50:09,550 --> 03:50:16,350 Our final speaker is Dr. Mariana Chilton, who is a faculty member and researcher at Drexel 2847 03:50:16,350 --> 03:50:24,300 University, and she will provide some insights into bigger-picture topics related to food 2848 03:50:24,300 --> 03:50:29,020 insecurity and what are some of those drivers of inequities in food insecurity? 2849 03:50:29,020 --> 03:50:34,420 So she's going to explore what are the structural drivers and social determinants of health 2850 03:50:34,420 --> 03:50:36,260 that intersect with food insecurity? 2851 03:50:36,260 --> 03:50:41,000 What are the gaps and opportunities to address food insecurity and promote racial equity? 2852 03:50:41,000 --> 03:50:42,890 And we are so excited... 2853 03:50:42,890 --> 03:50:48,820 we are so excited to hear the exciting presentation from Dr. Chilton. 2854 03:50:48,820 --> 03:50:54,040 So, I'm going to turn it over to you, Dr. Chilton. 2855 03:50:54,040 --> 03:51:03,149 DR. MARIANA CHILTON: Hello, everyone, thank you so much for tuning into my talk on the gaps 2856 03:51:03,149 --> 03:51:08,550 and opportunities to address food insecurity and the promotion of racial equity. 2857 03:51:08,550 --> 03:51:09,550 My name is Mariana. 2858 03:51:09,550 --> 03:51:15,280 I'm a professor at Drexel University, School of Public Health, and I'm making this recording 2859 03:51:15,280 --> 03:51:20,540 on the lands of the Lenni-Lenape in the area around Philadelphia, Pennsylvania. 2860 03:51:20,540 --> 03:51:24,290 And I acknowledge their elders past, present, and future. 2861 03:51:24,290 --> 03:51:31,550 And I recognize that the land should be returned to them with restitution and reparations. 2862 03:51:31,550 --> 03:51:37,300 Also, almost all of the photos in this presentation are from Witnesses to Hunger. 2863 03:51:37,300 --> 03:51:40,300 So, this wasn't the full title of my talk. 2864 03:51:40,300 --> 03:51:45,390 The rest of the title is about 'Promotion of Racial Equity in the Context of Structural 2865 03:51:45,390 --> 03:51:47,890 and Social Determinants of Health.' 2866 03:51:47,890 --> 03:51:53,489 So, for you, this is an invitation to rethink and to remember what we're doing when we're 2867 03:51:53,489 --> 03:51:57,380 doing food insecurity research, and I encourage you to take good care because I will be talking 2868 03:51:57,380 --> 03:52:00,300 about traumatic events. 2869 03:52:00,300 --> 03:52:06,340 So first of all, I want us to take context more seriously than we currently do in the 2870 03:52:06,340 --> 03:52:08,109 world of food insecurity research. 2871 03:52:08,109 --> 03:52:10,840 I'll talk about racial and ethnic and gender disparities. 2872 03:52:10,840 --> 03:52:17,229 I'll talk about the importance of taking intersectional lens and also integrating critical race theory. 2873 03:52:17,229 --> 03:52:22,680 I'll talk about exposure to trauma and violence and how a life course approach helps us to 2874 03:52:22,680 --> 03:52:25,060 integrate attention to trauma and violence. 2875 03:52:25,060 --> 03:52:28,979 Then I'll get to the gaps and finally to the opportunities. 2876 03:52:28,979 --> 03:52:35,090 So, before I begin, I want to acknowledge the relationships that I've had with my research 2877 03:52:35,090 --> 03:52:37,771 participants over the last 25 years. 2878 03:52:37,771 --> 03:52:40,550 I used to work with the Southern Cheyenne and Arapahos and the Kiowa, Comanche, Caddo 2879 03:52:40,550 --> 03:52:44,979 in Delaware in western Oklahoma in the 1990s. 2880 03:52:44,979 --> 03:52:50,989 And for the past 21 years, I've worked with a lot of really beautiful families, primarily 2881 03:52:50,989 --> 03:52:57,949 black and Latina women, and I want to honor my relationships and my kinship with research 2882 03:52:57,949 --> 03:52:58,949 participants. 2883 03:52:58,949 --> 03:53:05,250 And I encourage you to take a moment at this point to also acknowledge and send some gratitude 2884 03:53:05,250 --> 03:53:10,690 to the research participants in your own studies and to remember their humanity. 2885 03:53:10,690 --> 03:53:16,449 First of all, I want to talk about the spectrum, food insecurity across the continuum. 2886 03:53:16,449 --> 03:53:18,670 So yes, food insecurity is not hunger. 2887 03:53:18,670 --> 03:53:23,010 I know many of us are frustrated with the conflation of these two terms. 2888 03:53:23,010 --> 03:53:28,239 But that does not mean that we can portray food insecurity as a mere technological expediency 2889 03:53:28,239 --> 03:53:34,890 without considering the context, we must remember that food insecurity is a part of a continuum. 2890 03:53:34,890 --> 03:53:41,380 So most of us, of course, are dealing with what sometimes is referred to as hidden hunger 2891 03:53:41,380 --> 03:53:48,470 or chronic food insecurity, but deeper forms of food insecurity are forms of starvation. 2892 03:53:48,470 --> 03:53:57,550 So, I want to start there and acknowledge the starvation of Indigenous people in the United States. 2893 03:53:57,550 --> 03:54:03,550 Starving Indigenous people was a part of... it was an act of war and genocide in this 2894 03:54:03,550 --> 03:54:07,540 country, and we have to remember that when we're talking about food insecurity among 2895 03:54:07,540 --> 03:54:08,909 American Indian populations. 2896 03:54:08,909 --> 03:54:15,220 So this is a famous photograph of people standing on top of millions of buffalo skulls. 2897 03:54:15,220 --> 03:54:21,750 And here's an example, in 1873, the American government killed 1.5 million buffalo in that 2898 03:54:21,750 --> 03:54:27,830 one year alone, and that was to starve Indigenous communities across the United States. 2899 03:54:27,830 --> 03:54:29,359 Who ordered this kind of murder? 2900 03:54:29,359 --> 03:54:36,859 That would be Buffalo Bill Cody, Union Major General Philip Sheridan, and the 18th President 2901 03:54:36,859 --> 03:54:38,200 Ulysses S. Grant. 2902 03:54:38,200 --> 03:54:42,689 This was systematic war and genocide, and we must remember that. 2903 03:54:42,689 --> 03:54:49,340 It wasn't just there were so many different ways that we starved American Indians into 2904 03:54:49,340 --> 03:54:55,920 submission, killing sheep as well that was happening up through the 1930s among the Navajo. 2905 03:54:55,920 --> 03:55:00,540 And we have to remember that whenever we're talking about hunger, especially among American 2906 03:55:00,540 --> 03:55:01,609 Indian communities. 2907 03:55:01,609 --> 03:55:07,260 This is why we must understand that hunger and food insecurity are a question of power 2908 03:55:07,260 --> 03:55:09,140 and domination. 2909 03:55:09,140 --> 03:55:15,300 Scholars have been talking about this for over 100 years of just identify a few Peter 2910 03:55:15,300 --> 03:55:21,409 Kropotkin talked about the importance of equity, he says, "In solving the question of bread, 2911 03:55:21,409 --> 03:55:26,189 we must accept the principle of equality which will force itself upon us to the exclusion 2912 03:55:26,189 --> 03:55:29,090 of every other solution." 2913 03:55:29,090 --> 03:55:31,399 I make the same argument today. 2914 03:55:31,399 --> 03:55:36,229 Josue de Castro talked about hunger is man-made. 2915 03:55:36,229 --> 03:55:42,030 He was the head of the Food and Agricultural Organization in the 1950s. 2916 03:55:42,030 --> 03:55:46,180 Of course, Martin Luther King talked about food insecurity quite often, he said, "It's 2917 03:55:46,180 --> 03:55:51,300 a crime for people to live in this rich nation and receive starvation wages." 2918 03:55:51,300 --> 03:55:59,239 Amartya Sen, Nobel laureate, talked about hunger is a form of entitlement failure and 2919 03:55:59,239 --> 03:56:04,540 that our focus on food has caused deep conceptual confusion. 2920 03:56:04,540 --> 03:56:11,170 And finally, most more recently, Mike Davis talked about how the British created massive 2921 03:56:11,170 --> 03:56:20,270 famines through harnessing British rule and neoliberalism, taking advantage of the El 2922 03:56:20,270 --> 03:56:21,960 Nino weather patterns. 2923 03:56:21,960 --> 03:56:28,620 He said, that, "Millions died not outside the modern world system but in the very process 2924 03:56:28,620 --> 03:56:33,260 of being forcibly incorporated into its economic and political structures. 2925 03:56:33,260 --> 03:56:36,790 They died in the golden age of Liberal Capitalism. 2926 03:56:36,790 --> 03:56:39,360 Indeed, they were murdered." 2927 03:56:39,360 --> 03:56:46,000 When the climate catastrophe is upon us, I want to make sure that we're also paying attention 2928 03:56:46,000 --> 03:56:52,630 to how the climate crisis affects food insecurity and will affect food insecurity today. 2929 03:56:52,630 --> 03:56:57,680 This is an example of a photograph from Hurricane Ida. 2930 03:56:57,680 --> 03:56:59,330 So are we paying enough attention? 2931 03:56:59,330 --> 03:57:04,300 Are we finding out ways to build resilience, collective resilience so that we can survive 2932 03:57:04,300 --> 03:57:07,229 the future when things will get even far worse? 2933 03:57:07,229 --> 03:57:13,140 In other words, perhaps we ought to think about our food as persons in the example from 2934 03:57:13,140 --> 03:57:17,739 the Ojibwe, who are now fighting to protect their waters and their lands and their rights 2935 03:57:17,739 --> 03:57:22,300 by suggesting that Manoomin is a person. 2936 03:57:22,300 --> 03:57:24,749 Manoomin has rights using the rights of nature. 2937 03:57:24,749 --> 03:57:29,960 So back to what's going on presently in terms of food insecurity, who has the highest rates 2938 03:57:29,960 --> 03:57:31,770 of food insecurity and why? 2939 03:57:31,770 --> 03:57:35,270 This also helps us understand the context. 2940 03:57:35,270 --> 03:57:40,180 Of course, Indigenous nations and communities have the highest rates of hunger on U.S. soil, 2941 03:57:40,180 --> 03:57:45,660 and among the Navajo, the rates were at 80% when they were last measured. 2942 03:57:45,660 --> 03:57:52,350 People with disabilities- extremely high rates around 40 percent nationally. 2943 03:57:52,350 --> 03:57:58,989 Households that are headed by women or friends have rates between 30 and 35 percent of food insecurity. 2944 03:57:58,989 --> 03:58:03,671 Of course, Black and African-American families, Latina families have rates that are two to 2945 03:58:03,671 --> 03:58:06,149 three times that of white. 2946 03:58:06,149 --> 03:58:09,069 People who are immigrants have extremely high rates. 2947 03:58:09,069 --> 03:58:14,310 People who are lesbian, gay, bi, transgender, queer, intersex or asexual, and beyond have 2948 03:58:14,310 --> 03:58:19,189 much higher rates than the general population, as well as people returning from prison. 2949 03:58:19,189 --> 03:58:22,090 What ties all of these communities together? 2950 03:58:22,090 --> 03:58:24,810 What is the common theme? 2951 03:58:24,810 --> 03:58:26,699 That would be discrimination. 2952 03:58:26,699 --> 03:58:29,409 This is what we must pay attention to. 2953 03:58:29,409 --> 03:58:34,710 So, we think about just racial and ethnic and gender disparities have continued to happen 2954 03:58:34,710 --> 03:58:40,140 since we've been measuring food insecurity back since 1995. 2955 03:58:40,140 --> 03:58:45,180 Looking at rates of food insecurity by race and ethnicity, we see that the United States 2956 03:58:45,180 --> 03:58:52,160 has made very little progress in reducing ethnic and racial disparities over time as 2957 03:58:52,160 --> 03:58:53,620 well in terms of gender. 2958 03:58:53,620 --> 03:58:58,909 Look at the rates of female, of the rates of women-headed households. 2959 03:58:58,909 --> 03:59:06,149 We have done nothing to reduce these disparities over time. 2960 03:59:06,149 --> 03:59:11,189 This is despite a robust nutrition assistance series of programs. 2961 03:59:11,189 --> 03:59:17,229 So we need different lenses of understanding to try to create better solutions, more targeted 2962 03:59:17,229 --> 03:59:21,240 solutions to reduce racial and gender disparities. 2963 03:59:21,240 --> 03:59:25,250 The first lens that we need to use is intersectionality. 2964 03:59:25,250 --> 03:59:27,330 Intersectionality was developed by Kimbery Crenshaw. 2965 03:59:27,330 --> 03:59:33,399 It's about recognizing how our current and historical legacies of simultaneous racism 2966 03:59:33,399 --> 03:59:39,110 and sexism, of course, by extension, homophobia, transphobia, and xenophobia create the oppressive 2967 03:59:39,110 --> 03:59:44,700 conditions that cause poor health, lack of rights and opportunities, and ongoing discrimination 2968 03:59:44,700 --> 03:59:46,770 against Black women, girls and fems. 2969 03:59:46,770 --> 03:59:51,590 This, of course, upends our current ways of thinking in our usual ways of trying to solve 2970 03:59:51,590 --> 03:59:52,590 problems. 2971 03:59:52,590 --> 03:59:58,680 But we must incorporate this recognition that oppression is intersectional. 2972 03:59:58,680 --> 04:00:03,210 Another way we can use, we can understand what's going on with food insecurity is focusing 2973 04:00:03,210 --> 04:00:10,100 in on using racial, critical race theory, which understands that racial and ethnic disparities 2974 04:00:10,100 --> 04:00:14,420 that we see today have their roots in racism in all our systems. 2975 04:00:14,420 --> 04:00:20,300 This makes, this means that we need to pay attention to history and making sure that 2976 04:00:20,300 --> 04:00:23,290 we are tracking inequity across the generations. 2977 04:00:23,290 --> 04:00:29,029 So understanding these ways of, these two lenses of understanding help us to see that 2978 04:00:29,029 --> 04:00:33,710 the genocide of Indigenous people, land theft, and enslavement of African peoples are at 2979 04:00:33,710 --> 04:00:36,200 the root of the current social determinants of health. 2980 04:00:36,200 --> 04:00:44,000 Genocide and enslavement are forms of trauma where they create traumatic conditions. 2981 04:00:44,000 --> 04:00:51,330 Trauma is an emotional, cognitive, physical, spiritual, and relational response to a terrible 2982 04:00:51,330 --> 04:00:56,870 event or series of events such as accident, rape, or natural disaster. 2983 04:00:56,870 --> 04:01:02,520 Again, enslavement and colonization create traumatic conditions, and this can include 2984 04:01:02,520 --> 04:01:06,649 experiences of torture, starvation, imprisonment, etc. 2985 04:01:06,649 --> 04:01:13,920 At an individual level, we understand trauma to include issues, such as rape or intimate 2986 04:01:13,920 --> 04:01:21,660 partner violence, physical abuse, sexual abuse, and bullying, community trauma and beyond, 2987 04:01:21,660 --> 04:01:28,159 including traumatic grief, that's unresolved grief from death or witnessing terrible experiences. 2988 04:01:28,159 --> 04:01:32,700 But there's also forms of trauma that spread across the generations. 2989 04:01:32,700 --> 04:01:36,870 This can be historical or intergenerational trauma. 2990 04:01:36,870 --> 04:01:42,890 Historical trauma is the cumulative psychological and emotional wounding across generations 2991 04:01:42,890 --> 04:01:49,699 that emanates from massive group trauma, and this can include historical unresolved grief 2992 04:01:49,699 --> 04:01:54,819 that can accompany that kind of trauma, and that comes from Dr. Maria Yellow Horse Brave 2993 04:01:54,819 --> 04:01:55,819 Heart. 2994 04:01:55,819 --> 04:02:02,069 Intergenerational trauma are ways in which trauma is passed on through a family so it 2995 04:02:02,069 --> 04:02:07,899 can be experienced in one generation of a family and affect the health and well-being 2996 04:02:07,899 --> 04:02:09,890 of their descendants as well. 2997 04:02:09,890 --> 04:02:16,080 There is collective trauma, such as a cataclysmic event that shatters the basic fabric of society 2998 04:02:16,080 --> 04:02:18,880 or the loss of life and crisis of meaning. 2999 04:02:18,880 --> 04:02:26,060 One would argue that experiencing the COVID-19 pandemic over the past 18 months has been 3000 04:02:26,060 --> 04:02:27,870 a form of collective trauma. 3001 04:02:27,870 --> 04:02:34,970 Finally, a life course approach helps us to also understand how food insecurity and violence 3002 04:02:34,970 --> 04:02:36,680 can be transferred across the generations. 3003 04:02:36,680 --> 04:02:41,710 If we think about early childhood and the brain growth during early childhood, that 3004 04:02:41,710 --> 04:02:45,640 any kind of toxic stress can damage the brain architecture. 3005 04:02:45,640 --> 04:02:53,550 So any kind of nutritional deprivation in early in life can have severe lifelong consequences. 3006 04:02:53,550 --> 04:02:59,479 As an example, many of you may be familiar with adverse childhood experiences, this can 3007 04:02:59,479 --> 04:03:05,930 be abuse or neglect or household instability inclusive of having a parent who was incarcerated 3008 04:03:05,930 --> 04:03:08,779 or witnessing abuse in the household. 3009 04:03:08,779 --> 04:03:13,919 Families that have three or more ACEs are considered to have ACEs high. 3010 04:03:13,919 --> 04:03:18,620 And there's a lot of research that's coming out now on the relationship between ACEs and 3011 04:03:18,620 --> 04:03:24,061 household food insecurity as an example of how ACEs and food insecurity are related. 3012 04:03:24,061 --> 04:03:29,439 I'll introduce you to a publication I did with Dylan Jackson and several other authors 3013 04:03:29,439 --> 04:03:32,279 based on the 2016 National Survey of Children's Health. 3014 04:03:32,279 --> 04:03:39,970 Our sample size was over 50,000 and you can see with 3+ ACEs or ACEs high when there were 3015 04:03:39,970 --> 04:03:44,520 people, when compared with people with no adverse childhood experience exposure, exposure 3016 04:03:44,520 --> 04:03:50,479 to three or more adverse experiences corresponded to an eightfold increase in the relative 3017 04:03:50,479 --> 04:03:53,779 risk of moderate to severe food insecurity. 3018 04:03:53,779 --> 04:04:01,239 If you look at what also is going on individually, like individual ACEs, you'll see that those 3019 04:04:01,239 --> 04:04:06,600 who live with people who had a drug or alcohol problem or had experienced unfair treatment 3020 04:04:06,600 --> 04:04:13,109 because of race and ethnicity had a fourfold increase in moderate to severe food insecurity. 3021 04:04:13,109 --> 04:04:19,840 Very similarly, those who experienced or who witnessed physical violence in their home 3022 04:04:19,840 --> 04:04:24,760 also had major increased risk of moderate to severe food insecurity. 3023 04:04:24,760 --> 04:04:26,930 There is plenty of evidence out there. 3024 04:04:26,930 --> 04:04:30,199 It tends to be neglected or ignored. 3025 04:04:30,199 --> 04:04:33,560 Please take a screenshot and become familiar with the evidence. 3026 04:04:33,560 --> 04:04:39,470 So what I want us to do is pay more attention to racism and sexism, violence and injustice, 3027 04:04:39,470 --> 04:04:44,750 how these are related to disrupted relationships and isolation, poor school and job performance, 3028 04:04:44,750 --> 04:04:49,239 poor physical and mental health, and precarious living conditions, of course, which manifest 3029 04:04:49,239 --> 04:04:54,360 in economic insecurity, in which manifest in food insecurity and other insecurities. 3030 04:04:54,360 --> 04:04:58,900 And, of course, poor health, which most of us do our research at that level. 3031 04:04:58,900 --> 04:05:04,170 However, most of us are skating along the surface, and that's because we tend to take 3032 04:05:04,170 --> 04:05:07,271 a biomedical approach and focus primarily on food. 3033 04:05:07,271 --> 04:05:12,439 But if we continue to invest our resources and our interventions that... interventions 3034 04:05:12,439 --> 04:05:19,990 at this level, we are going to see more and more diminishing returns because we are neglecting 3035 04:05:19,990 --> 04:05:23,319 the other issues that are going on underneath. 3036 04:05:23,319 --> 04:05:29,550 So I'm recommending that we focus more on racism and sexism and violence and how these 3037 04:05:29,550 --> 04:05:34,130 are related to the kinds of conditions that create economic insecurity. 3038 04:05:34,130 --> 04:05:40,330 So, I am inviting us to allow ourselves to recognize and name the violence associated 3039 04:05:40,330 --> 04:05:42,890 with food insecurity. 3040 04:05:42,890 --> 04:05:47,180 Recognizing that low wages and their relationship to food insecurity is about being devalued, 3041 04:05:47,180 --> 04:05:53,210 that's a type of violence against working people, how we have discriminatory policies, 3042 04:05:53,210 --> 04:05:58,120 paying more attention to adverse childhood experiences, and of course, remembering that 3043 04:05:58,120 --> 04:06:00,530 food insecurity is rooted in our relationships. 3044 04:06:00,530 --> 04:06:03,750 That is, it is about power and control. 3045 04:06:03,750 --> 04:06:08,310 People in power, primarily white and western European, who have a history of oppressing 3046 04:06:08,310 --> 04:06:13,010 minorities and marginalizing people by harnessing techniques of domination. 3047 04:06:13,010 --> 04:06:16,720 Some of these I've already talked about. 3048 04:06:16,720 --> 04:06:19,530 So the gaps are our limitations and our ideology. 3049 04:06:19,530 --> 04:06:22,420 Again, we tend to stay at the surface. 3050 04:06:22,420 --> 04:06:29,440 Our scientific methods are also quite limited, we tend to utilize a very western European 3051 04:06:29,440 --> 04:06:31,949 framework, which looks at very proximate outcomes. 3052 04:06:31,949 --> 04:06:37,319 We have a lack of diversity of people doing the research, especially those who have lived 3053 04:06:37,319 --> 04:06:43,609 experience with economic precarity setting and who are not able to set the research agenda 3054 04:06:43,609 --> 04:06:44,609 and do the research. 3055 04:06:44,609 --> 04:06:50,270 I'd also have to say that the NIH itself is quite limited because of our demand for clinical 3056 04:06:50,270 --> 04:06:56,920 and nutritional outcomes, the short windows of research funding and our desire for outcomes. 3057 04:06:56,920 --> 04:07:00,760 And finally, I'd say a lack of desire to change our status quo. 3058 04:07:00,760 --> 04:07:05,460 So, we have lots of opportunities to broaden our framework frameworks and ideologies. 3059 04:07:05,460 --> 04:07:10,580 We need to take more intersectional approaches and integrate critical race theory, focusing 3060 04:07:10,580 --> 04:07:15,950 on equity in emancipation, human rights and rights of nature, incorporating more clear 3061 04:07:15,950 --> 04:07:21,720 theory and feminist theory, being trauma informed in our approach in our look at outcomes. 3062 04:07:21,720 --> 04:07:28,590 And I'd have to say we need to incorporate more Indigenous ethnic ethics of reciprocity 3063 04:07:28,590 --> 04:07:29,590 and mutuality. 3064 04:07:29,590 --> 04:07:34,420 This, again, can be incorporated into our methodologies, doing more participatory and 3065 04:07:34,420 --> 04:07:41,270 inclusive type of research studies, incorporating more anthropology and ethnography and ecology, 3066 04:07:41,270 --> 04:07:47,710 focusing less on description more on intervention and action, becoming more joyful in our approaches 3067 04:07:47,710 --> 04:07:49,470 and our methodologies. 3068 04:07:49,470 --> 04:07:53,899 And finally focusing in on financial, social, and spiritual outcomes, as well as mental 3069 04:07:53,899 --> 04:07:56,040 and physical well-being of humans. 3070 04:07:56,040 --> 04:07:58,530 So these are achievable and possible. 3071 04:07:58,530 --> 04:08:02,281 As a quick example, I give you one of our own studies from the Building Wealth and Health 3072 04:08:02,281 --> 04:08:07,979 Network, which is a trauma-informed approach to helping primarily women who are on temporary 3073 04:08:07,979 --> 04:08:15,630 assistance for needy families to come together in groups, to come together in a circle to 3074 04:08:15,630 --> 04:08:21,930 address issues of trauma, racism, and discrimination, and also to build up their bank accounts and 3075 04:08:21,930 --> 04:08:24,760 their sense of financial security. 3076 04:08:24,760 --> 04:08:28,140 We had no food involved, and we were able to reduce the odds of household food insecurity 3077 04:08:28,140 --> 04:08:34,330 by 64%, and we were especially successful among those who had experienced violence. 3078 04:08:34,330 --> 04:08:36,239 So this is very possible. 3079 04:08:36,239 --> 04:08:41,310 If you want to learn more about the context behind food insecurity and hunger, you can 3080 04:08:41,310 --> 04:08:48,920 read our article the Catherine Alaimo, Sonya Jones and I, wrote last year it came out and 3081 04:08:48,920 --> 04:08:51,320 present knowledge and nutrition, chapter 17. 3082 04:08:51,320 --> 04:08:57,149 More specific opportunities are we must prioritize research, prioritize funding researchers from 3083 04:08:57,149 --> 04:09:04,510 minorities and marginalized groups and prioritize research that promotes action in policy change. 3084 04:09:04,510 --> 04:09:09,199 That means taking an intersectional lens on work and wages and labor laws, making sure 3085 04:09:09,199 --> 04:09:14,500 that we're focusing in more on interventions that help to improve racial and gender equity, 3086 04:09:14,500 --> 04:09:20,369 focusing in on promoting Indigenous sovereignty and free prior and informed consent and ensuring 3087 04:09:20,369 --> 04:09:25,050 that we're building resilience in our ecosystems and our human interactions. 3088 04:09:25,050 --> 04:09:30,250 There's lots of excitement now with the Biden administration, with changes in the SNAP calculation 3089 04:09:30,250 --> 04:09:32,580 as well as pandemic EBT. 3090 04:09:32,580 --> 04:09:37,240 Let's take an intersectional lens to ensure that we're focusing in, especially on Black 3091 04:09:37,240 --> 04:09:40,500 women and Indigenous women, and improvements for them. 3092 04:09:40,500 --> 04:09:45,489 We also need to make sure that we're developing models based on more transformative policies 3093 04:09:45,489 --> 04:09:53,050 that address equity, such as reparations for enslavement and reparations, and rematriation 3094 04:09:53,050 --> 04:09:58,360 for Indigenous sovereignty, focusing on universal basic income or minimum wage increases. 3095 04:09:58,360 --> 04:10:04,859 And what could happen if we could get police out of schools and making sure that we're 3096 04:10:04,859 --> 04:10:07,766 preparing for the climate catastrophe? 3097 04:10:07,766 --> 04:10:12,300 Finally, we'd like to make a plug for trauma-informed solutions that are healing centered to do 3098 04:10:12,300 --> 04:10:13,310 more violence prevention. 3099 04:10:13,310 --> 04:10:19,220 If we can reduce violence, I know I can guarantee you will reduce economic insecurity and food 3100 04:10:19,220 --> 04:10:20,382 insecurity. 3101 04:10:20,382 --> 04:10:26,375 And finally, thinking and acting for seven generations ahead. Thank you so much for listening in to this talk. 3102 04:10:26,375 --> 04:10:29,109 Please feel free to stay in touch. 3103 04:10:39,945 --> 04:10:47,270 DR. ANGELA ODOMS-YOUNG: Thank you so much, Dr. Chilton, for that very thoughtful and reflective talk. 3104 04:10:47,270 --> 04:10:54,460 I will start out actually with the first question as we see people to some, I think people will 3105 04:10:54,460 --> 04:10:57,020 start putting questions in the chat. 3106 04:10:57,020 --> 04:11:05,069 If you haven't already, I know that this is a very reflective talk in the sense that it 3107 04:11:05,069 --> 04:11:10,970 explores some issues that we don't always think about in the context of food insecurity. 3108 04:11:10,970 --> 04:11:15,100 And you talked a little bit about using critical race theory. 3109 04:11:15,100 --> 04:11:18,949 You talked about other types of methodological approaches. 3110 04:11:18,949 --> 04:11:28,240 And one limitation, even as someone who studies race and I have an interest of race is training. 3111 04:11:28,240 --> 04:11:30,989 We have a lot of people who are trained as nutritionists. 3112 04:11:30,989 --> 04:11:31,989 I'm trained as a nutritionist. 3113 04:11:31,989 --> 04:11:34,290 I am at the nutrition department. 3114 04:11:34,290 --> 04:11:42,300 So one question that I would have, particularly for researchers, is what recommendations would 3115 04:11:42,300 --> 04:11:47,540 you have when it comes to training of how we should be trained in the next generation 3116 04:11:47,540 --> 04:11:52,260 of researchers to meet some of the opportunities that you mentioned? 3117 04:11:52,260 --> 04:11:57,399 DR. MARIANA CHILTON: Thank you so much for the question, and I too have suffered from the 3118 04:11:57,399 --> 04:12:02,960 lack of training and I've had to learn by doing and often learn by the seat of my pants. 3119 04:12:02,960 --> 04:12:08,790 I'd have to say that I've also learned from my direct experiences in working with the 3120 04:12:08,790 --> 04:12:13,750 Southern Trans Arapaho, as well as Black and Latinx women in Philadelphia and all over 3121 04:12:13,750 --> 04:12:20,220 the East Coast, who have forced me to pay closer attention to issues of racism and sexism 3122 04:12:20,220 --> 04:12:25,270 and discrimination. 3123 04:12:25,270 --> 04:12:31,729 You know, I think it's very clear that those who have who get training in nutrition know 3124 04:12:31,729 --> 04:12:37,790 a lot about micronutrients and also about the food system, but there is a kind of blindness 3125 04:12:37,790 --> 04:12:40,689 that all of us have, or I don't want to say blindness. 3126 04:12:40,689 --> 04:12:48,800 I mean, sort of a lack of awareness that it's the structure of higher education, which is 3127 04:12:48,800 --> 04:12:52,069 also dominated by a white supremacist type of culture. 3128 04:12:52,069 --> 04:12:56,239 So it's not really just in nutrition, it's also in public health that people are lacking 3129 04:12:56,239 --> 04:12:57,239 this training. 3130 04:12:57,239 --> 04:13:00,100 It's also in sociology and beyond. 3131 04:13:00,100 --> 04:13:05,790 So, I think if more of us food insecurity researchers could pay greater attention to 3132 04:13:05,790 --> 04:13:11,020 issues of racism and discrimination and incorporate more history, I think that we would be able 3133 04:13:11,020 --> 04:13:16,449 to draw in people from other disciplines to start to engage on food insecurity work. 3134 04:13:16,449 --> 04:13:21,600 And I think that we all have to take a broader approach and be unafraid to talk about critical 3135 04:13:21,600 --> 04:13:22,600 race theory. 3136 04:13:22,600 --> 04:13:27,430 We need to bring, you know, hopefully, the teachers K through 12 are starting to integrate 3137 04:13:27,430 --> 04:13:33,020 more attention to racism and discrimination and to the harms of colonization. 3138 04:13:33,020 --> 04:13:36,439 We just all have to do better and we have to make room in our courses. 3139 04:13:36,439 --> 04:13:38,619 We can't say, "Oh, today we're going to talk about food. 3140 04:13:38,619 --> 04:13:40,899 And tomorrow we'll talk about racism and discrimination." 3141 04:13:40,899 --> 04:13:47,190 Everything should be seen through the lens of racism, sexism, capitalism to allow us 3142 04:13:47,190 --> 04:13:49,770 to have a broader understanding of what's going on. 3143 04:13:49,770 --> 04:13:55,569 We have to take these things that are called blinders, which I don't like the word, but 3144 04:13:55,569 --> 04:13:58,229 we have to take them off and all of us have to do it. 3145 04:13:58,229 --> 04:14:00,989 We can all do better, myself included. 3146 04:14:00,989 --> 04:14:04,880 DR. ANGELA ODOMS-YOUNG: Thank you, we have a question in the chat. 3147 04:14:04,880 --> 04:14:11,670 Given the importance of intersectionality, what do you believe is the ideal role of food 3148 04:14:11,670 --> 04:14:14,980 banks now and in the future in addressing food insecurity? 3149 04:14:14,980 --> 04:14:17,750 DR. MARIANA CHILTON: Thanks for the question. 3150 04:14:17,750 --> 04:14:23,279 I don't think there is an ideal role for food banks because emergency food and food banks 3151 04:14:23,279 --> 04:14:28,010 are not accountable really to anyone and not even accountable to their local communities. 3152 04:14:28,010 --> 04:14:34,140 They tend to be accountable to their funders and tend to focus on the distribution of food 3153 04:14:34,140 --> 04:14:38,960 without paying attention to issues of racial and gender equity, and to the trauma that's 3154 04:14:38,960 --> 04:14:42,510 underneath so much of hunger, so much hunger today. 3155 04:14:42,510 --> 04:14:49,290 I think that existing food banks could do a lot more to really engage with the communities 3156 04:14:49,290 --> 04:14:56,109 that they serve to do more, to be less of a one-way experience, to create opportunities 3157 04:14:56,109 --> 04:14:57,960 for mutuality and solidarity. 3158 04:14:57,960 --> 04:15:05,300 So perhaps, turning food banks into a cooperative, like a food cooperative where people are proud 3159 04:15:05,300 --> 04:15:09,330 to go to the food bank because they know that they're contributing to their own community 3160 04:15:09,330 --> 04:15:11,319 and that they're contributing to community resilience. 3161 04:15:11,319 --> 04:15:17,300 Anything that food banks can do that promote community resilience, promote human rights, 3162 04:15:17,300 --> 04:15:26,640 the right to food, and promote food as a right, not as a charity we'll be in good stead. 3163 04:15:26,640 --> 04:15:34,950 DR. ANGELA ODOMS-YOUNG: How would you recommend funding for grants to be more equitable across 3164 04:15:34,950 --> 04:15:39,689 diverse investigators so more work can be done in this area? 3165 04:15:39,689 --> 04:15:42,689 Do you have any recommendations about funding? 3166 04:15:42,689 --> 04:15:46,260 Funding is always an issue that comes up. 3167 04:15:46,260 --> 04:15:50,800 How what recommendations do you have for funding to be more equitable? 3168 04:15:50,800 --> 04:15:57,720 DR. MARIANA CHILTON: Well, I think that those who are who control the purse strings of our 3169 04:15:57,720 --> 04:16:03,590 funding mechanism need to look in the mirror very closely about whether they're really 3170 04:16:03,590 --> 04:16:07,710 adopting an equity type of lens. 3171 04:16:07,710 --> 04:16:10,729 It's painful to do that because we tend to be attach. 3172 04:16:10,729 --> 04:16:16,930 My guess is that we get attached to those who have long CVs and excellent training, 3173 04:16:16,930 --> 04:16:21,100 supposedly excellent training, and who know how to write those grants. 3174 04:16:21,100 --> 04:16:29,250 I think that if NIH and USDA could really take into account issues of vulnerability 3175 04:16:29,250 --> 04:16:35,270 and personal and lived experience and make a commitment that for the next five to ten 3176 04:16:35,270 --> 04:16:41,689 years, that they will prioritize researchers and investigators from minoritized communities 3177 04:16:41,689 --> 04:16:48,199 and create opportunities for them to get training and to propose new solutions to propose new 3178 04:16:48,199 --> 04:16:49,500 methodologies. 3179 04:16:49,500 --> 04:16:51,729 And many of them are not new. 3180 04:16:51,729 --> 04:16:54,979 Some of them are older or, you know, thousands of years old. 3181 04:16:54,979 --> 04:17:00,689 These types of scientific methodologies, Indigenous methodologies, and also I know that philanthropy 3182 04:17:00,689 --> 04:17:09,170 is really is rife with issues of racism and sexism, and classism. 3183 04:17:09,170 --> 04:17:14,500 And there are funders that are looking to decolonize the way that they fund do their 3184 04:17:14,500 --> 04:17:17,050 funding. 3185 04:17:17,050 --> 04:17:21,970 And when I can circle back around, I can do a quick Google search on some people that 3186 04:17:21,970 --> 04:17:28,569 are working on helping to find ways to ensure that funding gets directly into Indigenous 3187 04:17:28,569 --> 04:17:31,890 communities and in partnership with Indigenous communities. 3188 04:17:31,890 --> 04:17:37,480 We have to, I think about Ruthie Wilson Gilmore, who's an abolitionist and a geographer, has 3189 04:17:37,480 --> 04:17:43,920 talked about, if we're going to, she talk about abolition. 3190 04:17:43,920 --> 04:17:47,830 But I take an abolitionist approach to food insecurity. 3191 04:17:47,830 --> 04:17:52,850 We have to change, now, we have to just change one thing, which is everything. 3192 04:17:52,850 --> 04:17:57,960 The funders are part of the problem, the way that we teach about food insecurity, the way 3193 04:17:57,960 --> 04:18:00,430 that we teach our methodologies are part of the problem. 3194 04:18:00,430 --> 04:18:05,260 The way that we understand the history or lack thereof of food insecurity is a part 3195 04:18:05,260 --> 04:18:06,260 of the problem. 3196 04:18:06,260 --> 04:18:12,189 So all of us have a part to play in centering an equity type of a lens. 3197 04:18:12,189 --> 04:18:21,140 DR. ANGELA ODOMS-YOUNG: The next question from our attendees says, "I absolutely loved your 3198 04:18:21,140 --> 04:18:23,000 presentation, Dr Chilton. 3199 04:18:23,000 --> 04:18:29,930 I run a food insecurity program in North Philadelphia out of the Center for Urban Bioethics. 3200 04:18:29,930 --> 04:18:36,119 Racism continues to have a huge impact on healthy food access, and the two biggest barriers 3201 04:18:36,119 --> 04:18:41,630 we see to healthy food access are cost and access. 3202 04:18:41,630 --> 04:18:49,740 What do you see as the role of academic medical centers and academic centers that are housed 3203 04:18:49,740 --> 04:18:52,780 in neighborhoods that suffer from food insecurity?" 3204 04:18:52,780 --> 04:18:59,739 DR. MARIANA CHILTON: That's a little bit like the question of what can what is the ideal 3205 04:18:59,739 --> 04:19:02,350 position for food banks, right? 3206 04:19:02,350 --> 04:19:12,250 When I think about university systems and health care system, we are a part of the problem. 3207 04:19:12,250 --> 04:19:17,600 Our institutions tend to suck resilience up neighborhoods in which we are housed. 3208 04:19:17,600 --> 04:19:21,710 Drexel is a case in point in the City of Philadelphia. 3209 04:19:21,710 --> 04:19:26,340 So, it's not just about working with people from the neighborhoods, but it's also about 3210 04:19:26,340 --> 04:19:32,609 working with your home institution to ensure that they're investing in housing in the local 3211 04:19:32,609 --> 04:19:39,439 community, that they're investing in building community resilience, that they're hiring 3212 04:19:39,439 --> 04:19:47,260 local people for all of their staff and university jobs and paying taxes. 3213 04:19:47,260 --> 04:19:53,540 I know that that's not really a popular sentiment, but across the country, there are examples 3214 04:19:53,540 --> 04:19:59,449 of university starting to pay taxes and starting and stopping what many consider to be freeloading 3215 04:19:59,449 --> 04:20:03,310 through the 501(c)(3) status when you have it from the case. 3216 04:20:03,310 --> 04:20:09,739 Philadelphia, where you have Drexel, Penn, Jefferson, and Temple all claiming 501(c)(3) 3217 04:20:09,739 --> 04:20:16,449 status, they are not paying taxes and they are devaluing housing in their neighborhoods 3218 04:20:16,449 --> 04:20:23,489 and not allowing for a better tax base to increase to improve local schools and local 3219 04:20:23,489 --> 04:20:24,489 infrastructure. 3220 04:20:24,489 --> 04:20:30,699 So, there's so much that we ought to be doing this way beyond our individual research studies 3221 04:20:30,699 --> 04:20:33,080 or our practice opportunities we have. 3222 04:20:33,080 --> 04:20:37,619 There are other ways of getting the universities involved, and I wish you the best of luck. 3223 04:20:37,619 --> 04:20:41,319 I have been trying to do it at Drexel to not much success. 3224 04:20:41,319 --> 04:20:47,979 DR. ANGELA ODOMS-YOUNG: Yeah, I have one, we're going down to the final questions, but this 3225 04:20:47,979 --> 04:20:51,630 is a similar question about public universities. 3226 04:20:51,630 --> 04:20:56,090 The focus on food systems and they're generally land grants. 3227 04:20:56,090 --> 04:21:00,949 This is the opposite of Indigenous ways of looking at land. 3228 04:21:00,949 --> 04:21:03,939 How do you reconcile this? 3229 04:21:03,939 --> 04:21:09,659 Looking at where research tends to happen is hard to go back and it's hard. 3230 04:21:09,659 --> 04:21:12,439 It's very difficult to go back, back. 3231 04:21:12,439 --> 04:21:20,680 So, as we move forward, how do we create those equitable structures to make sure that we're 3232 04:21:20,680 --> 04:21:27,300 able to, as you talked about, address some of the needs by looking at structural determinants? 3233 04:21:27,300 --> 04:21:32,399 DR. MARIANA CHILTON: Oh, thank you so much for the question to go forward. 3234 04:21:32,399 --> 04:21:38,310 We have to go back and we have to acknowledge that a lot of the land grant institutions 3235 04:21:38,310 --> 04:21:41,630 were, those were stolen from native communities. 3236 04:21:41,630 --> 04:21:48,949 So the, you know, the land grant institutions need to work alongside go and share funding 3237 04:21:48,949 --> 04:21:53,680 where the Indigenous communities that are either still in place or that have been displaced. 3238 04:21:53,680 --> 04:22:00,660 I think about in Pennsylvania, the Pennsylvania land grant institutions should be connecting 3239 04:22:00,660 --> 04:22:08,110 with the (AUDIO DISTORTS) tribes that were dislocated or, you know, walked through various 3240 04:22:08,110 --> 04:22:13,090 terrible situations of Trail of Tears and to make reparations 3241 04:22:13,090 --> 04:22:20,120 and to really invest real money, and I'm not talking, you know, $100,000 Grant or $50,000 3242 04:22:20,120 --> 04:22:22,260 consulting type of thing. 3243 04:22:22,260 --> 04:22:27,270 I'm talking about millions and billions of dollars that ought to be going back to native 3244 04:22:27,270 --> 04:22:28,300 communities. 3245 04:22:28,300 --> 04:22:33,649 If we're going to promote Indigenous sovereignty, as Dr Jernigan talked about, we have to invest 3246 04:22:33,649 --> 04:22:34,649 in that. 3247 04:22:34,649 --> 04:22:40,149 And we, those of us who do this kind of work and who have some power in our own institutions 3248 04:22:40,149 --> 04:22:45,300 should be working to dismantle the current infrastructure that we have in our land grant 3249 04:22:45,300 --> 04:22:46,300 institutions. 3250 04:22:46,300 --> 04:22:48,380 So it is extremely necessary. 3251 04:22:48,380 --> 04:22:54,900 You can go back to go forward and there has to be a repayment and retribution, sorry, 3252 04:22:54,900 --> 04:23:03,510 restoration, not retribution, maybe retribution, but restoration to help people get, you know, 3253 04:23:03,510 --> 04:23:05,489 start to even infield. 3254 04:23:05,489 --> 04:23:10,680 DR. ANGELA ODOMS-YOUNG: Well, thank you so much, Dr. Chilton, for your thoughtful presentation 3255 04:23:10,680 --> 04:23:14,729 and your response to the questions and comments. 3256 04:23:14,729 --> 04:23:19,880 We're going to move into to our closing and so we appreciate your participation. 3257 04:23:19,880 --> 04:23:21,560 Thank you. 3258 04:23:21,560 --> 04:23:29,300 So, I would like to thank all of our panelists and participants today for sharing your expertise, 3259 04:23:29,300 --> 04:23:36,430 your research ideas, your thoughtful questions so we can have a better response to address 3260 04:23:36,430 --> 04:23:37,810 food insecurity. 3261 04:23:37,810 --> 04:23:43,520 We were able to explore what existing data is in place, understand and explore some of 3262 04:23:43,520 --> 04:23:48,790 the pathways that link food insecurity and health outcomes. 3263 04:23:48,790 --> 04:23:51,930 Also, talk a little bit about nutrition and security. 3264 04:23:51,930 --> 04:23:58,560 And then look at different sectors where we are, what do we know when it comes to interventions 3265 04:23:58,560 --> 04:24:01,530 in both communities and within the health care sector. 3266 04:24:01,530 --> 04:24:04,000 Tomorrow, please join us again. 3267 04:24:04,000 --> 04:24:09,330 We start at 12:30 Eastern for Day 2. 3268 04:24:09,330 --> 04:24:16,510 We'll start out with a recap of day one, and so tomorrow's agenda will also cover the neighborhood 3269 04:24:16,510 --> 04:24:24,100 food environment and its role in health outcomes, health disparities, and the role of how modifications 3270 04:24:24,100 --> 04:24:28,748 in neighborhood food environments can help promote health equity. 3271 04:24:28,748 --> 04:24:37,770 So, thank you again for participating and joining and we look forward to seeing you tomorrow. Have a good night.