DR. KAREN GLANZ: Good afternoon, everybody.
Welcome to the NIH Workshop on Food Insecurity, Neighborhood Food Environments, and Neighborhood
Health Disparities: The State of the Science.
My name is Karen Glanz from the University of Pennsylvania, and I have the pleasure of
co-chairing this workshop with Angela Odoms-Young from Cornell University.
I want to be sure to encourage everyone to participate in discussions throughout the
workshop by using the chat box feature on the online platform.
We encourage a robust dialogue, so please don’t be shy.
Pose your questions as they come up in the chat box.
We’re thrilled to have so many of you registered for this workshop that will take place over
three days.
Our goal in the workshop is to review the state of the science, identify research gaps
and opportunities, and suggest innovative research strategies that will inform policy
and practice to address and prevent diet-related health disparities and promote health equity.
We look forward to hearing from you as you help us to meet this ambitious goal.
We have more than 40 speakers, a full agenda across three afternoons of the workshop.
Day one will focus on the state of the science in the areas of food insecurity, its health
impacts, and effective interventions.
Tomorrow, on the second day, we will cover research that addresses the neighborhood food
environment and health.
And on the third day, we’ll focus on implementation science, policy, and community-based research
across both areas–what works and what doesn’t.
The overall objectives of this workshop are to describe the current state of research
and gaps and opportunities, to summarize the state of science, and to provide research
suggestions.
As you’ve heard, there are many institutes, centers, and other agencies that have contributed
to planning this workshop and that are eager to hear from both the speakers and the audience
with ideas about how we should be moving forward in the most effective way to make the food
environment as equitable, secure, and healthful for all as possible.
I’m now delighted to introduce Dr. Eliseo J. Pérez-Stable, Director of the National
Institute of Minority Health and Health Disparities, and Deputy Undersecretary Stacy Dean from
USDA’s Food, Nutrition, and Consumer Services, who will provide opening remarks.
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
this really critically important topic.
It has received all too little attention in many ways across the NIH.
All right.
I’m the...
I am the Director of the National Institute on Minority Health and Health Disparities,
so in that regard, we’re always concerned about all populations and all aspects of health.
I will share with you some thoughts and general perspectives on health equity as we see them
from NIMHD.
So, some big topics that...I think of as both a clinician-scientist, and Director of NIMHD.
So, measurement in this field has been tedious, and as a not only consumer of the science
but actually working with secondary data analysis when we try to factor in issues around nutrition,
the challenge is, what is in the dataset, and what has been collected?
So, I think this is an area that needs some new thought.
Defining a healthy diet has changed over the years.
Now, you could say we’ve been able to modify and go back or get away from one thing and
go to another.
But this has probably confused our population as the marketing approach to unhealthy diets
has continued without hesitation.
Originally, I think humans were designed really for avoiding undernutrition as we know, and
much of...in some parts of the world, we still face this incredible challenge, but overnutrition
gets very little attention and, in fact, is now the dominant problem that we face as a
society, not just in high-income countries but in most middle-income countries and low-income
countries as well.
Food production is a problem.
I don’t remember the exact number, but over 3,000 calories are produced every day in the
U.S. for consumption, and you all know how many calories we’re supposed to eat on a daily
basis to keep our weight.
So, clearly someone is interested in generating overnutrition in the population.
Less access to healthy foods is really easy… and unhealthy foods is really easy and cheap.
Ultra-processed food, that’s usually what’s marketed, and healthy foods are harder to
obtain.
And then the obesity epidemic and its consequences really has developed during my career.
If I go back to 1980 to where we are in 2021, over these 40 years, you know what has happened.
So, from the context of NIMHD, we focus on populations with health disparities.
The first three bullets in this slide are legislated to us, so all racial and ethnic
minorities as defined by the U.S. Census, all poor people of any color, and then underserved
rural residents.
In 2016, we declared sexual and gender minorities as a population with health disparities for
NIH research purposes, and I think it has triggered a number of changes in how we consider
this population and collect data.
We endorse the idea that social disadvantage, that it results in part from being subject
to discrimination or racism and from being underserved in health care is a unifying factor
for all of these populations with health disparities.
And then a health outcome that is worse in one of these populations compared to a reference
group defined, in our view, a health disparity.
We also start with the premise that race/ethnicity as a social construct, a self-identified social
construct, and socioeconomic status or social class are fundamental in determining health.
It has to be proven otherwise that they don’t matter before you don’t measure them or
don’t consider them.
And I think this is a paradigm shift for many clinicians-scientists who have not worked
in populations or community engagement or in disparities research.
Race/ethnicity and SES predict so many things like life expectancy, total mortality, that
are not really fully explained or understood.
African Americans, for example, have more strokes when compared to whites for the same
exact level of systolic blood pressure, and the hazard ratio is two.
Most chronic diseases are more common in persons who are poor.
And again, it’s not only because of poor behavior.
And then among persons with diabetes, all racial and ethnic minorities compared to whites
have less heart disease and more end-stage renal disease over a 10-year prospective registry
follow-up in the Kaiser Permanente of Northern California.
Again, this doesn’t have explanations, so we often just don’t talk about it as much.
This is data from the CDC published several years ago, illustrating the importance of
using both race/ethnicity and socioeconomic status.
It shows the rate of...the prevalence of obesity among youth by the education level of the
head of the household.
And I’m trying to contrast the lowest level of education of the head of household, so
less than high school, with some college.
And you can see there is a clear-cut SES gradient in the prevalence of obesity among the youth
living in this household in all racial and ethnic groups.
We also can see that for Blacks and Latinos, it is much higher, to begin with, for those
head of households/homes with less than high school for the head of household.
And the benefit from having some college, although present, is not as marked as it is
for whites.
And so, this is more research that’s needed this way.
We need to stratify.
We need to look at both.
They’re not mutually exclusive, nor are they fully explaining each other’s findings.
In NIMHD, we have focused with standardized measurements of social determinants of health
over about the past 3.5 to 4 years.
So, structural social determinants of health, so things that are not measured by individual
respondents, some of them are listed here.
Of course, you see access to healthy and affordable food here, the topic of this workshop, one
of the topics of this workshop, as well as green space and sidewalks.
So, I think that you can get a sense.
We have created a website on the PHENX Toolkit website that the NIH has.
Our logo here, the three colored houses in the bottom corner, with measures that we have
vetted through the PHENX process with an expert external panel.
We completed one phase and launched this in May of 2020.
We are now about to start a second phase where a lot of the measures we’re going to look
at are primarily structural social determinants.
NIMHD also has a framework that we’ve published, now almost three years ago, developed by staff
on prompting whi I arrived.
And as you can see, it is multiple levels of influence, not only going from the individual
to societal, and from the biological and behavioral over here to the health care system and all
the health outcomes that these relate to.
We use the framework for guiding our work.
Most of our funding continues to still be in this first column, the individual, but
we are certainly striving to expand those dimensions.
And let me just end with a couple of data points.
This is about racism, and just to put it on the table, it affects how–these are data
from the Kaiser Family Foundation published about 5 years ago–and that over a third of
Latinos and over a half of African-Americans agreed with the statement that in the past
30 days, they were treated unfairly because of racial and ethnic background in store
or work.
And this, I think, cannot be ignored.
Past 30 days, not the lifetime, not the last year, past 30 days.
Racism is alive and well in our country.
These are data from a while back to illustrate the rates of food security among Americans
by race/ethnicity, as well as educational level.
And you can see that Latinos and African-Americans have about a 70...65...70 percent
rate of food security.
And looking at more recent data, these numbers are probably not quite this low.
They’re probably closer to 80 percent, but they’re still about 10,15 percentage points
below what white Americans have in terms of food security.
But the gradient by educational level is more dramatic, with over 90 percent of college
graduates feeling secure compared to 60 percent of those with less than high school.
And then a couple of studies funded by NIMHD, this is a trend in consumption of ultra-processed
foods among youth.
I found this quite striking that over the course of these, what is not quite 20 years
or so, using multiple cross-sectional data from the NHANES unprocessed ultra-processed
foods went up.
And the biggest increase...and they went up in all groups, all educational groups, all
race and ethnic groups, it didn’t matter.
Ultra-processed foods accounted for greater increases in calories in Black and Mexican
youth.
But it went up in everyone, and it went from a total of ultra-processed foods and ready-to-heat-and-eat
dishes, which accounted for about 11 percent of daily calories, as opposed to 2 percent.
We have a problem.
And then this is a cool study that is yet to evaluate all the outcomes.
The Navajo Nation, with an R01-funded and supported in part by an R01 that we funded through the
Tribal Epidemiology Center there, extended their 2 percent junk food tax.
It is the first such tax in the U.S. or in sovereign Tribal nations, and it has led to a generation
of revenue.
We hope that it will also lead to a decrease in junk food consumption.
Thank you very much for your attention, and I think I’ll turn it back to Karen.
DR. STACY DEAN: Good afternoon.
I’m Stacy Dean, USDA’s Deputy Undersecretary for Food, Nutrition, and Consumer Services.
USDA is honored to be a part of this event.
Thank you to NIH for hosting and to all of you for your interest in this important topic.
Though we can’t be physically together, it’s still inspiring to be in community
with others who are dedicated to the cause of combating food insecurity and diet-related
disparity.
I can’t imagine a more relevant time for these discussions.
The pandemic has placed unprecedented stress on American families, leaving in its wake
millions struggling to make ends meet and put food on the table.
The latest census data show that 17 million adults, one in 13, reported not having enough
food to eat, and the crisis of food insecurity is particularly acute in communities of color.
Today, about one in seven Black and one in eight Latino adults live in food-insecure
households.
Compare this with the one in 12 white non-Hispanic adults living in food insecurity, and you
quickly see the stark inequity in disparity.
Families with kids are also more likely to struggle, leaving far too many parents with
the impossible decision of having to choose between serving less to their family or skipping
meals themselves.
We hear those statistics, and we see people in need all around us every single day, but
sometimes we forget to stop and take a moment to really acknowledge and reflect on the impact
this pandemic has had on all of us.
This has been and continues to be a scary and uncertain time, and we’re going to be
dealing with the impacts of that for years to come.
But amidst that uncertainty, we also have the opportunity to learn from our collective
experience, both to help those in need now and better serve them going forward.
The Biden administration has a goal to build back better, to come out the other end of
this pandemic in a better place than where we began.
For USDA’s Food and Nutrition Service, that means we’re going to strengthen our programs
and remove barriers to make sure all families have a reliable food safety net, one that
promotes not only food security but also nutrition security, the idea that all people at all
times have access to a healthy diet.
Nutrition insecurity is a complex challenge, and one with lasting negative consequences.
For example, today one-fifth of American children are obese.
Not surprisingly, research shows this increases the likelihood of obesity in adulthood, creating
financial strains on families, our health care system, and our ability to remain safe
and secure as a nation.
USDA’s Nutrition Assistance programs can help.
They are some of the most far-reaching powerful tools available to ensure that all Americans
have access to a healthy diet, and their need has never been felt so urgently.
I know you’ll be hearing more from Dr. Melissa Abelev on the specifics of these programs
and how we intend to move forward in the coming months and years.
Yet, we have a lot of work ahead to ensure that programs serve everyone evenly and fairly.
Nutrition and security, like food insecurity, disproportionately burden low-income families,
especially those in communities of color.
Black, Latino, Native American, as well as people living in rural low-income counties,
suffer the greatest disparities with regard to nutritional quality and corresponding diet-related
disease.
We cannot combat food and nutrition insecurity without acknowledging and committing to break
down the cycle of racial inequity at play.
We need to tackle inequities in our programs while offering a constructive voice in the
racial justice conversation.
In the Biden administration, this is central to our approach.
We’re working to bake it into everything we do and everything we set out to accomplish,
and I believe it starts with listening.
We must spend more time with those with lived experiences of our programs, both participating
in and operating them to ensure what we do and how we do it is helping those who rely
on our services.
We must also expand the roster of who we’re listening to, finding those who engage with
or are impacted by and rely on our programs and using their experience to guide our next steps.
That’s how we’ll make strides in fighting food and nutrition insecurity.
That’s how we’ll start to close the disparities, and it’s how we will build back better.
During this workshop, you’ll get to hear more of the specifics about the federal response
to hunger, and I know my colleague, Melissa for one, will be sharing more about what we’re
actually doing at the Food and Nutrition Service to put these promises into action.
She’ll talk about WIC, child nutrition, SNAP education, amongst other things, as
key components to addressing nutrition insecurity.
But I want to emphasize again that we are open to listening and hearing from you as
well.
You can be partners in this effort.
You have valuable perspectives and expertise, and we invite you to share those with us.
We want to be in evidence.
We want our policymaking to be evidence-based.
Our nation’s families are counting on us.
So, let’s not wait any longer.
Let’s build back better.
Thank you and enjoy the workshop.
DR. ANGELA ODOMS-YOUNG: Thank you so much to our opening speakers.
As Karen mentioned, my name is Angela Odoms-Young.
I’m an Associate Professor in the Division of Nutritional Sciences at Cornell University,
and I serve as a co-chair for this workshop.
I’m very excited to introduce Session 1.
The focus of Session 1 is really to provide an overview and the definitions, measurement,
and also the federal programs that are here to address food insecurity.
So, the objectives of the session, we plan to describe food insecurity and its growing
trends in the U.S., discuss how food insecurity is measured, really dig into the key lessons
from the 25 years of food insecurity measurement, identify gaps in knowledge and research opportunities
in the area of food insecurity, and describe how food insecurity is addressed through federal
safety net programs in the U.S., as was mentioned during the opening.
So, we have three speakers for this session.
Our first speaker will provide an overview of food insecurity and food and nutrition
service programs.
And we have Melissa Abelev from the Food and Nutrition Service in the United States Department
of Agriculture.
We will have an overview of food insecurity measurement by Dr. Alisha Coleman-Jensen from
the Economic Research Service in the United States Department of Agriculture.
And then Dr. Sheri Weiser from–a professor in medicine at the University of California,
San Francisco–will talk about the pathophysiology linking food insecurity with obesity and
cardiometabolic diseases.
So, we’re going to start our session with Dr. Abelev from the Food and Nutrition Service
at the USDA.
DR. MELISSA ABELEV: Hello, everyone.
I’m Melissa Abelev.
I’m the Assistant Deputy Administrator for Policy Support at USDA’s Food and Nutrition
Service.
I was asked today to provide an overview of food insecurity and the FNS programs.
And so, I want to talk about what our programs are, why they’re important, how we responded
to COVID, and then provide a definition of nutrition security, which is an administration
priority, and how this is different than food security, in general and what we’re doing
in the nutrition security space and what we’re focusing on next.
So, first, what are FNS’s programs?
Most simplistically, they’re the federal response to hunger in this country.
FNS administers about 15 different nutrition assistance programs, the largest of which
is the Supplemental Nutrition Assistance Program, or SNAP, commonly known as food stamps.
The next largest group of programs are the child nutrition programs.
Most people are probably familiar with school breakfast and school lunch.
We also have the Child and Adult Daycare Program, which serves about 4 million people each day,
The Summer Food Service Program, which is for when schools are not in session so that
children in need can still get access to meals, a smaller program called the Fresh Fruit and
Vegetable Program, which is targeted towards schools in low-income neighborhoods so that
they can get snacks outside of the regular meal service time of fresh fruits and vegetables,
and then the Special Milk Program, which provides milk to schools that are not providing the
National School Lunch Program.
The Women, Infants and Children program is targeted towards pregnant and postpartum
women, as well as infants and children through their fifth birthday who were at nutrition
risk.
It provides a food prescription, which is a specific list of foods that people can buy
at the grocery store that are targeted towards addressing this specific nutrition risks of
those groups.
We also have some Small Farmers Market programs that provide funds for people to purchase
things at participating farmers markets.
And then the last group of programs are our Food Distribution programs, which is where
USDA is actually purchasing food commodities and then distributing them through our partners,
including the Emergency Food Assistance program, the Food Distribution program on Indian reservations,
the Commodity Supplemental Food program, which is targeted towards the elderly, and then
USDA Foods and Schools.
That last one is the reimbursement that schools get for participating in National School Lunch
and School Breakfast, comes through a combination of cash reimbursements, as well as the ability
to make purchases of USDA Foods for about 20 percent of their reimbursement.
And so, they can benefit from the buying power of USDA and purchase commodity foods in that way.
So, now that we’ve talked about what the programs are, let’s go over a little bit
about why our programs are important.
I want to present some data from the census department’s pulse survey.
And that data is about food insufficiency.
I do want to note that my colleague at USDA, Alisha Coleman-Jensen is speaking after me.
s\She is going to be describing food security, which is a validated measure; that USDA collects
once a year, every year and has for about 25 years.
What the pulse survey did was not the validated measure, they asked just a couple of questions.
And so, it’s really not providing solid data on food security.
What it’s doing is looking at food insufficiency.
And it’s better to really considered the results of that data more as trends than as
specific point estimates.
And so, there’s some differences in the data that I’ll present and what Alisha will
present.
But I think what the pulse survey does is it really provides trends that you can think
of over time, and a particular snapshot specific to the pandemic time.
So, with that caveat, let me present a little bit about what we were seeing.
So, we know that even outside of the pandemic, food insecurity is a real challenge for millions
of American families.
Throughout the pandemic, it continued to be a challenge, and it remains so now.
Although what we can see in this chart, which is showing the food insufficiency rates over
the course of the entire pandemic, is that the rates do seem to be declining, and we’re
at the lowest in the last data collection in August, as they were in the entire pandemic.
A couple of things are important here, the Biden administration is really focusing on
ensuring that we’re looking at our programs through a racial equity lens.
And so, really looking at: are programs affecting people of different groups in different ways?
This graph doesn’t show the effect of our programs per se, but it does look at how different
groups are experiencing food insufficiency.
So, the gray line, which is the second from the bottom, is if you look at all of the data
together, if you separate it out though by racial group, then you can see that while
white families are struggling, their struggle is less severe than black and Hispanic families.
And so, what you see is that, about one in eight Latino families were experiencing food
insufficiency or reporting food insufficiency in the last seven days, in the last data collection.
For Black families, that’s one in seven.
And for white families, that’s one in 18.
Further what the data show us for families with children; is that they are reporting
food insufficiency 45 percent more frequently than households without children.
So, you see on there, the blue line is households without children, the red line is households
with children.
The data also indicate that the initiatives we’ve implemented for schools have been
a very important source of food assistance for families with children.
We see that the pandemic EBT, which I’ll describe later, was a key resource for families
with children, as were the grab and go meals, which were both initiatives FNS had to pivot
to once the crisis started.
So, with that data in mind, let’s talk about FNS’s response to COVID.
As everything began shutting down in March 2020, because of the pandemic, FNS had to
pivot pretty quickly to ensure that our programs were still responding to the need.
We issued over 800 different flexibilities and waivers over the course of the pandemic
and continue to extend them as needed in order to make sure that our programs are serving
those in need.
In SNAP, the key changes were increasing the benefit amounts through emergency allotments
and a 15 percent increase so that families had more resources to purchase groceries.
In the Child Nutrition programs and in WIC, those programs actually have requirements
for face-to-face in-person for certain aspects of the program.
So, one of the key things that we did was remove that requirement for the two programs...
or the two types of programs.
And for Child Nutrition programs, we created grab and go options so that schools could
distribute multiple meals at a time and that parents could pick them up and took away the
requirement that children had to pick them up.
We also established the pandemic EBT program, which either on an existing SNAP card or by
distributing a new EBT card to any child in the household who was eligible for free and
reduced price lunch, and then it was expanded to the CACFP program.
But you could get up to $6.82 per child, per day on that EBT card that could then be used
like a SNAP card for purchasing groceries at the grocery store.
In the Food Distribution program, we got additional funds to be able to distribute to our local
partners.
In the TEFAP program, we made some changes with disaster household distribution, so that
things could get to people faster.
And there was additional funding in the FDPIR, as well.
As I mentioned upfront, there’s food security, but there’s also nutrition security, which
is a Biden administration and Secretary Vilsack priority.
And so, many have asked what is nutrition security?
Nutrition security is really ensuring that people have, at all times, access to nutritious
foods to support a healthy and active life.
So, that’s a long quote, but in sum, it’s really looking at access to nutritious food.
So, I’ll talk a little bit about those two capitalized words but access is ensuring
that everybody knows of the program, if they’re eligible, how long they’re eligible, and
that people of different racial groups are not getting differential access, but that
instead, we’re ensuring that the programs are implemented and designed in a way that
people who are eligible for them can access them easily.
We also want to make sure that folks are not simply able to get food but that they’re
able to get nutritious food, and that they have the nutrition education and resources
to know how to purchase and prepare nutritious foods to support a healthy life.
What are FNS’s programs focusing on in order to support nutrition security?
FNS is taking a number of actions in order to ensure access to nutritious food.
One of the largest activities we’re working on is the WIC 390 Innovations Fund.
The American Rescue Plan Act provided FNS with $390 million over the next few years
to develop innovative outreach strategies, modernize the program and include waivers
and flexibility to pilot some new approaches aimed at increasing participation and redemption
of benefits.
Participation in WIC declines pretty substantially after the first birthday, even though children
are eligible up through their fifth birthday.
And so, part of the focus of this fund is really ensuring that WIC participants know
of their continued eligibility and that the program is designed in such a way that access
is simple, it’s not cumbersome, and it’s something that participants can really access
the benefits that are really targeted towards their nutrition risk so that we can continue
to improve this public health program.
We are doing that, in part, through learning from the SNAP online purchasing pilot which
was expanded substantially during the pandemic, from a small pilot in about six
cities, to now where almost 94 percent of SNAP participants have access to online purchasing.
We will be learning from those lessons and developing a WIC online purchasing program
as well.
We’re also updating the WIC food package rule based on a NASEM review, which is the National
Academies of Sciences review that was conducted a few years ago, as well as the updated Dietary
Guidelines for Americans.
The latest report which was published in December of 2020, included for the first time, standards
for pregnant women and children under the age of two.
So, using those science-based guidance documents, we will be updating the WIC food package rule
to ensure nutritious food.
We’re also looking further at the child nutrition meal standards for School Lunch,
School Breakfast and CACFP to ensure that they are aligning with the Dietary Guidelines
for Americans.
And in SNAP, we just finished the Thrifty Food Plan Re-evaluation.
The Thrifty Food Plan is what forms the basis of SNAP allotments.
And I’ll talk about that in just a minute.
The Thrifty Food Plan Re-evaluation was important because in the 2018 Farm Bill, Congress required
us to look at that and put it on a 5-year interval so that we’ll be doing re-evaluations
of the Thrifty every 5 years.
Prior to that, it was at the Secretary’s discretion.
And it had only been done a couple of times in the 40-year lifespan of the Thrifty Food Plan.
And the last time was about 15 years ago in 2006.
In fact, President Biden was so committed to this that in his very first week in office,
he had an executive order encouraging USDA to prioritize this review.
So, we did that, we looked at that, it’s based on a mathematical optimization model
that looks at what people eat, what the dietary guidelines say people should be eating, what
food compositions and the vitamins and minerals in our foods, how they support healthy eating.
And then what the cost of groceries is today, puts those into a mathematical optimization
model, which I’m happy to describe in more detail for those of you who are interested
and looks at what is the cost of the nutritious practical cost-effective diet,
And the results of that re-evaluation indicated that the maximum allotments for SNAP would
need to increase by about 21 percent.
What that means, practically, when that translates into SNAP benefits, is about $43 increase
per month for a one-person household or an $80 increase per month for a two-person household,
which constitute about 70 percent of SNAP households.
So, to break that down even further by person, what that means is about $1.19 per person
per day increase, or about 40 cents per meal per person increase, when these go into effect
on October 1.
And the big additional efforts that the department is focusing on in order to promote nutrition
security, which again is access to nutritious foods, is really looking at its nutrition
promotion and nutrition education efforts to ensure that folks have access to the foods
but then also that they know how to purchase and prepare foods that can support a healthy
and active life.
So, one of the things that we’re working on is enhancing SNAP and SNAP education.
Many people don’t necessarily know that a big part of the SNAP budget is the SNAP
nutrition education and obesity prevention grants, which each state gets each year to
create community-based and public health approaches, to facilitate greater access to nutrition
education, enhanced collaboration and coordination among program partners and implementing agencies
and improve dietary behaviors among eligible audiences.
We’re working to guide implementation of expanded SNAP benefits through the Thrifty
to encourage adequate diets, positive nutrition behaviors among SNAP program partners, SNAP
retailers, farmer’s markets, consumer venues, and SNAP-Ed implementing agencies and program
participants.
We also want to increase federal-level cross-program collaboration partnerships and guidance
for cross-program Food and Nutrition security support to our state partners.
SNAP and SNAP-Ed will be working with other FNS programs such as the Child Nutrition programs,
and the Center for Nutrition and Policy Promotion to engage in the development of communications,
promotion interventions and educational strategies to increase awareness and access to resources
around the Thrifty and its implementation.
And SNAP will be emphasizing, engaging underserved communities, diverse stakeholders and service
providers throughout this process.
As I mentioned also, the WIC 390 program is looking at innovative strategies to ensure
that folks have access to our programs, and will be redeeming the benefits to which they’re
eligible so that they’re getting access to that important food prescription, which
is based on specific nutrition needs.
Thank you very much for the opportunity to speak today.
I am happy to answer questions when the time comes up.
DR. ALISHA COLEMAN-JENSEN: Hello, my name is Alisha Coleman-Jensen from USDA's Economic Research
Service.
I’m pleased to speak with you today about food security.
I’ll be presenting an overview of food security measurement, and talking about food security
data sources, and also presenting findings from our most recent annual food security
report, Household Food Security in the United States in 2020.
To make sure we’re all on a same page, let’s start by talking about the food security
definitions.
So, food security means access at all times to enough food for an active healthy life
for all household members.
Food insecurity means being unable, at some time during the year, to provide adequate
food for one or more household members because of a lack of resources.
I’d like to unpack this definition a little bit.
So, being able...unable at some time during the year, a household may experience food
insecurity for a single occurrence. For example, if they experienced unemployment, whereas
some other households may be more chronically food insecure.
But a single occurrence of food insecurity would classify a household as food insecure
for the year.
Being unable to provide adequate food for one or more household members.
Food insecurity is measured at the household level.
And if a single household member’s food insecure, the entire household is food insecure.
This is particularly relevant when we think about food insecurity among children.
Because in some instances, parents will report food insecurity among adults, but children
may be less affected by reduced food intake.
But if a single household member is food insecure, the entire household would be classified as
food insecure.
And finally, because of a lack of resources.
So, this is about not having enough money or other resources to acquire food.
This is not about dieting, or not having enough time to eat.
Very low food security is the more severe range of food insecurity.
Very low food security means that normal eating patterns of some household members were disrupted
at times during the year and their food intake reduced because they could not afford enough
food.
What we...what we mean by normal eating patterns being disrupted, is that households are telling
us that they’re skipping meals, or in more severe situations, going an entire day without
eating.
And they’re telling us that they’re just not able to get enough to eat because they
can’t afford enough food.
How is food security measured?
Food insecurity is a continuum like many things, and early research showed that food insecurity
was a managed process, meaning households had some control over how food insecurity
is experienced.
So, we hope that all households can afford enough healthy food.
But as households may begin to struggle with food insecurity, as their food security deteriorates,
households may become anxious about the household food supply and try to stretch their food
and food budget.
They may try to juggle household spending to try to maintain food security.
As food insecurity worsens, households may reduce the quality and variety of food or
rely on low cost foods.
And this is defined as having low food security.
And as food insecurity becomes still more severe, adults may reduce their own food intake
while trying to ensure children get enough to eat.
And in the most severe situations, we see reductions in food intake among children.
And this reduced food intake is classified as very low food security.
Households are asked a series of 10 questions about food insecurity for the household as
a whole, and adults in the household.
Households with children are asked an additional eight items about children’s food insecurity.
These questions follow the full range of severity of food insecurity that we discussed on the
last slide.
Households must respond affirmatively to at least three items indicating food insecurity
to be considered food insecure.
And here I show some examples of food security survey items.
And the full set of items can be found on the Economic Research Service website, and
also in our annual report that was released last week.
We worried whether our food would run out before we got money to buy more, was that
often, sometimes or never true for you in the last 12 months?
We couldn’t afford to eat balanced meals?
Was that often, sometimes, or never true for you in the last 12 months?
A more severe item.
In the last 12 months, did you ever cut the size of your meals or skip meals because there
wasn’t enough money for food?
And the most severe item:
In the last 12 months, did you ever not eat for a whole day because there wasn’t enough
money for food?
And you’ll notice that these questions follow along with the definition, in terms of stipulating
that this is about not having enough money for food, and also asking about the last 12
months, if these experiences sometimes or ever happened in the last 12 months.
There are a number of surveys that include food security measures.
First, I’ll talk about the Current Population Survey Food Security Supplement.
The Current Population Survey is also the source for federal poverty and unemployment
statistics.
The U.S. Census Bureau conducts the Food Security Survey for USDA's Economic Research Service
and December each year, as a supplement to Census's monthly Current Population Survey.
The 2020 food security survey interviewed about 34,330 households and was a representative
sample of the U.S. civilian population.
And the Current Population Survey Food Security Supplement also includes information on use
of food programs, food spending, and because it’s part of the CPS income on an...information
on income and employment.
There are a number of surveys that can be used to understand the relationships between
health and food insecurity.
And some of those are shown here.
The National Health and Nutrition Examination Survey includes food security, and also detailed
information on food intake and nutritional status along with health measures.
The National Health Interview Survey includes the food security measure and also detailed
information on health status, chronic conditions, health care access and use and can also be
linked to the Medical Expenditure Panel Survey to assess linkages between food insecurity
and medical expenditures.
The National Survey of Children’s Health, includes a single item about food insufficiency,
so this is a little bit different from the food insecurity measure but is similar in
concept.
Then NSCH also includes measures of children’s health status and access to health care and
information on the family, neighborhood, school, and social contexts.
These data sources can be used to understand the multiple pathways through which food
insecurity can affect health, such as diet and nutrition, adherence to medical treatment,
health care utilization, and other factors.
I’d like to turn now and talk about the findings from our most recent annual food
security report.
In 2020, 89.5 percent of U.S. households were food secure throughout the year.
Food secure, again, means that they had consistent access to adequate food for active healthy
living for all household members throughout the year.
10.5 percent of households were food insecure.
That’s about 13.8 million households.
Food insecure households were unable, at some time during the year, to provide adequate
quantity or quality of food for one or more household members due to a lack of resources
We separate food insecure households into either having low food security or
very low food security.
Households reporting food acquisition problems, but few, if any indications of reduced food
intake, are classified as low food secure.
For these households, inadequate food meant primarily inadequate in quality, variety, or
desirability, not in quantity of food.
6.6 percent of U.S. households were categorized as having low food security in 2020.
3.9 percent of U.S. households were very low food secure in 2020.
This subset of food insecure households was in the more severe range of food insecurity,
and that’s about 5.1 million households.
Households classified as having had very low food security reported that normal eating
patterns of some household members were disrupted at times during the year and their food intake
reduced below levels they considered appropriate.
Most households with very low food security reported that an adult in the household had
been hungry at times, but did not eat because there wasn’t enough money for food.
I’d like to turn now to trends in food insecurity to provide some historical context.
In 2008, food insecurity increased substantially to 14.6 percent and peaked at 14.9 percent
in 2011.
We saw several subsequent declines in food insecurity since that time, and in 2019, 10.5
percent of U.S. households were food insecure, and the percentage of U.S. households that were
food insecure in 2020 was unchanged from 2019.
The COVID-19 pandemic began in the United States in 2020 and affected public health
and the economy, and there was a substantial increase in assistance, including nutrition
assistance and other benefits.
These many changes may have affected food insecurity in different ways, and our recent
annual Food Security Report does not provide an analysis of possible causal impacts, but
we do know from previous research that increases in nutrition assistance and other benefits
help to reduce food insecurity.
The red line near the bottom of the graph shows the prevalence of very low food security.
In 2008, 5.7 percent of U.S. households experienced very low food security, and we saw declines
to 4.1 percent in 2019.
In 2020, 3.9 percent of U.S. households were food insecure and that difference from 2019
to 2020 was not statistically significant.
This chart includes a lot of information, if you’re interested in looking at the underlying
statistics in more detail, you can find those in Table Two of Household Food Security in
the United States in 2020.
They’re also available on our website.
So there are two important takeaways from this chart, first, it shows those household
characteristics related to a higher prevalence of food insecurity.
The patterns of groups with a relatively higher prevalence of food insecurity tend to be the
same from year to year.
In 2020, food insecurity rates were highest for all households with children, especially
for single mother families and single father families.
Food insecurity rates were higher for households with reference persons who are Black, non-Hispanic,
or Hispanic.
A reference person is an adult household member in the survey who owns or rents the housing
units sampled.
Food insecurity is also higher for low income households, which is to be expected given
that food insecurity is related to constrained resources.
Food insecurity was higher in principal cities within metropolitan areas and in non-metropolitan
areas.
The second takeaway from this graph is that it shows changes in the prevalence of food
insecurity by household characteristics between 2019 and 2020.
Bars marked with an asterisk show a statistically significant change in the prevalence rate
between years.
Statistical significance is related both to the size of the change and the margins of
error around the estimates.
Food insecurity increased significantly for all households with children from 2019 to
2020, for married couples with children and for households with Black non-Hispanic reference
persons.
Food insecurity declined significantly for men and women living alone in households with
white non-Hispanic reference persons.
We’ll also be talking during the conference about the use of federal nutrition assistance
programs.
In 2020, about 55 percent of food insecure households participated in one of the three
largest nutrition assistance programs. About 42 percent use SNAP.
Note that these are based on self-reported survey data, so there is some underreporting
of program participation.
Participation in the free or reduced price school lunch program was lower than in 2019,
likely due to school closures and possibly because parents did not report receive grab
and go school meals.
About 6.7 percent of U.S. households used food pantries in 2020, and that is an increase
from 2019.
Use of food pantries was more common among those that were food insecure. Thirty-seven percent
of food insecure households used food pantries and 46 percent of very low food secure households
used food pantries.
Use of soup kitchens was much less common overall, but similarly more common among those
that were food insecure.
I’ll close this presentation by reminding that food insecurity was unchanged from 10.5
percent in 2019 to 10.5 percent in 2020.
There were some increases in food insecurity for some groups, including households with
children.
The prevalence of food insecurity increased for all households with children from 13.6
percent in 2019 to 14.8 percent in 2020.
I also want to refer you to our website for a lot of information on survey tools and modules
to measure food insecurity in U.S. households, along with information on data, graphics, and
interactive charts that you can download and a number of research reports and articles
that may be of interest.
Thank you.
DR. SHERI WEISER: Hello, I’m Sheri Weiser, a professor of medicine in the Division of
HIV, Infectious Diseases, and Global Medicine at UCSF, and I’m also founding co-director
for the University of California-wide Center on Climate, Health, and Equity.
Today, I’m going to be reviewing the pathways through which food insecurity increases the
risk of obesity and cardiometabolic diseases.
So in 2020, 38 million people in the U.S. lived in food insecure households.
We know that food insecurity is an important driver of chronic health disparities and disproportionately
impacts low income and minoritized groups.
Food insecurity negatively impacts cardiometabolic health along the entire cascade of care, from
disease acquisition to linkage and retention in care to higher morbidity and mortality.
There’s in fact, a large body of literature linking food insecurity to obesity, and also,
studies show that sociodemographic characteristics can modify associations.
So, for example, in a study by Penn et. al., using behavioral risk factor surveillance
system data from over 66,000 adults in 12 U.S. states, people who were food insecure had
32 percent higher odds of being obese in adjusted analyses and being female and having gone
to college as you can see, increased these odds further among food insecure adults.
As another example, a 2017 study from Hernandez et al., used National Health Interview Survey
data to look at the association between food insecurity and obesity and also to determine
whether this association differed by race and ethnicity.
So while black and Hispanic women were more likely to be food insecure and obese compared
to white women, food insecurity, in fact, predicted obesity more strongly among white women.
So specifically, white adults who were food insecure had 41 percent higher odds of being
obese or overweight, compared to 29 percent higher odds for food insecure Hispanic women.
And there was no association between food insecurity and overweight and obesity status
among Black women.
In addition to obesity, we know that food insecurity has been linked with a number of
cardiometabolic and chronic diseases.
And just for a few examples, food insecurity has been associated with 27 percent higher
odds of having diabetes, 42 percent higher odds of hypertension, 38 percent higher odds
of nonalcoholic fatty liver disease, 46 percent higher odds of chronic kidney disease and
53 percent higher odds of cardiovascular disease mortality.
So food insecurity and cardiometabolic health are really intertwined in a vicious cycle,
with each enhancing vulnerability to and worsening the severity of the other condition.
On the left, you can see that there are several structural drivers of food insecurity at the
community level including socioeconomic factors like poverty and lack of access to education
and social factors, like gender inequality and racism.
Food insecurity typically operates at the level of the household and is also influenced
by other household level factors like family structure and social support.
Food insecurity, in turn, shapes cardiometabolic health outcomes through mental health, immune
activation and behavioral pathways.
These then contribute to conditions like obesity, diabetes, hypertension and cardiovascular
disease, and also worse outcomes among those affected.
Morbidity from these conditions then can lead to more acute care utilization, greater out-of-pocket
health expenses, and also to poor health-related quality of life and then this creates a vicious
cycle.
As people get sicker, they have worse functioning, incur greater medical costs and may face unemployment,
all of which then go back to exacerbate food insecurity.
And I’m going to be using this framework as a way to walk through data on these mechanistic
pathways.
So let’s start with the mental health pathway.
Food insecurity leads to stress, depression, anxiety, and increased drug and alcohol use
disorders, and this poor overall mental health status then has important impacts on our physical
health.
So in a systematic review and meta-analysis comprising over 300,000 individuals across
10 countries, food insecurity was found to increase the odds of depression by 40 percent.
The association was in fact universal across the 10 countries, and 19 studies looked at
and was greater among the elderly and also intensified with worsening severity of food
insecurity.
The odds of stress was similarly higher, so 34 percent greater in food insecure groups,
and this was observed in all countries included in the study.
Finally, food insecurity was associated with 29 percent greater odds of anxiety in North
American settings.
So, our team found similar results in the Women’s Interagency HIV study, which is a prospective
cohort study of women at risk of or living with HIV from multiple sites in the United
States.
So we used longitudinal data over a three year period and found that current and past
food insecurity were associated with higher depression scores measured on the CESD depression
scale and lower mental health summary scores on the MOS HIV Mental Health Summary Score.
And this was even after adjusting for sociodemographic and clinical factors.
And Whittle et. al., in our group also found that food insecurity was associated with higher
generalized anxiety disorder scores, post-traumatic stress disorder scores and perceived stress
scores in a dose-dependent manner.
Food insecurity can, in fact, alter metabolic processes through this stress pathway.
So specifically, food scarcity may trigger stress, which then activates the hypothalamic
pituitary adrenal axis or the HPA axis, and also stimulates glucocorticoid release, which
then can increase both visceral fat storage and accumulation.
Food scarcity-related stress can also activate the reward pathway and memory, and this can
explain why people that are stressed may be drawn to high fat, high sugar comfort foods.
High cortisol in response to stress has also been associated with increased caloric intake
and binge eating, particularly in women.
So we know that increased cortisol levels in turn can increase blood glucose and insulin
levels, which play a critical role in the pathogenesis of diabetes, and then stress
related alterations that are sympathetic and autonomic nervous system activity in the HPA
axis and also in inflammatory cytokines are associated with endothelial dysfunction,
increases in blood pressure and heart rate, and decreases in vascular reactivity.
In addition to stress, mental health problems related to food insecurity could also increase
the risk for cardiovascular and metabolic problems.
So a large scale meta analysis by Correll et. al., looked at the prevalence and incidence
of cardiovascular disease among patients with severe mental illness, and they found that
depression was associated with 75 percent greater odds of cardiovascular disease and
150 percent greater odds of coronary artery disease.
Another study from Singapore by Zhu et. al., which is shown in the figure on the left,
followed young adults with both type 1 and type 2 diabetes for 2 years, and they
found that those with anxiety at baseline consistently had higher levels of hemoglobin
A1c, than those without anxiety throughout the entire study period.
Moving on to the second pathway, food insecurity is associated with immune activation and inflammation,
which negatively affects health.
Poor diet quality also affects our microbiome, which impairs immune functioning, contributing
to worse cardiometabolic health.
So in this framework, from Kau et. al., published in Nature, we see that food insecurity and
subsequent undernutrition can really change the gut microbiota, which can impair both
gut and immune functioning and thereby make individuals more susceptible to infectious
diseases.
A suboptimal microbiome can also impair nutrient absorption, which then contributes to micronutrient
deficiencies.
So in addition to undernutrition, studies show that diet-induced perturbations of the
gut microbiome can precipitate obesity, insulin resistance, type 2 diabetes and other cardiometabolic
conditions, and this could occur through a variety of potential mechanisms, but including
immune activation through bacterial translocation.
Low fiber, high fat and high sugar diets, which we know are typical among individuals
with food insecurity, have also been shown to negatively impact the composition of the
gut microbiome.
And conversely, diets high in fruit and vegetables and low in meat are associated with a highly
diverse microbiota.
So turning to some data, a cross-sectional NHANES study with 12,000 participants by
Gowda et. al., looked at potential pathways through which food insecurity may be associated
with inflammation and adverse health outcomes.
So they found that highly food insecure individuals had 36 percent higher odds of having a high
white blood cell count and 21 percent higher odds of having higher CRP levels, and in mediation
models, white blood cell count was at least a partial mediator of the relationship between
food insecurity and C-reactive protein levels.
In our data from the wise cohort among women living with HIV in the United States, Leddy
et. al., found that food insecurity was associated with higher levels of inflammatory markers
such as TNFR1 and interleukin-6, in adjusted analyses.
And importantly, we saw significant effects, even among those who were both virally suppressed
and had high CD4 cell counts. So, CD4 cell counts greater than 500, which really suggests
that poor HIV control did not explain our associations.
We then hypothesized that this inflammation may be on the causal pathway between food
insecurity and higher morbidity and mortality.
And in the wise cohort, we also looked at how food insecurity impacts T-cell activation
and senescence.
Peters et. al., found that food insecurity was significantly associated with increased activation
of CD4 and CD8+T-cells, increased senescence, CD8+T-cells and decreased post-stimulation
CD4 and CD8+T-cells in adjusted analyses and similar to the last paper, the effects
also persisted even among those with well-controlled HIV.
Turning to the last pathway, we know that food insecurity impacts cardiometabolic health
through the adoption of unhealthful health behaviors. So this can include poor diet,
low physical activity, smoking, medication adherence and overall poor engagement and
care.
Hunger, so which is defined as the uneasy or painful sensation caused by a lack of food
or by the recurrent and involuntary lack of access to food, can really drive people to
adopt coping strategies to avoid it.
And these strategies can include things like eating low-cost and highly filling foods that
are calorically dense but nutrient poor, putting limited money towards food rather than towards
medical care, and also binge eating when food is available in anticipation of future food
challenges and all of these coping behaviors then both increase the risk of diet sensitive
diseases like diabetes and hypertension, and then lead to worse outcomes once affected.
Starting with diet quality, studies show that food insecurity leads to poor diet quality
in both adults and children, however, results are not consistent across studies.
For example, in this systematic review of 26 U.S. studies comprising 170 unique associations
between food insecurity and diet quality, 29 percent of associations were found to be
adverse and the majority of associations were not significant.
And this may be in part related to the expense and challenges in measuring diet quality in
epidemiologic study.
Diet and poor nutrition, in turn, have important implications for cardiometabolic disease.
So a study using nationally representative enhanced data by Micah et. al., found over 700,000
deaths from cardiometabolic disease, with more than 45 percent of these deaths associated
with poor nutritional intake.
8.5 percent of cardiometabolic deaths were attributable to low nut and seed intake, 8.2
percent to high processed meat consumption, 7.6 percent to low vegetable intake and 7.4
percent to high sugar sweetened beverages.
Aside from diet, food insecurity is also associated with smoking and lower physical activity,
which confers risk for cardiovascular disease.
For example, a study using a nationally representative sample of almost 5,000 adults by total, so
they found that those with food insecurity had 16 percent lower odds of having adequate
physical activity and in the Weiser cohort, we found a dose-dependent relationship
between food insecurity and smoking, and specifically, participants with very low food security had
approximately 2.3 times the odds of smoking compared to people with high food security.
Food insecurity also interferes with adherence to treatment and care recommendations, so
in a large study by Herman et al., using National Health Interview Survey data from over 65,000
adults under the age of 65, a dose-dependent relationship was found between food insecurity
and cost-related medication underuse.
For example, those experiencing severe food insecurity had 3.7 times the odds of skipping
their medications, 3.8 times the odds of taking less medication than prescribed, four times the
odds of being delayed in filling their prescriptions and over four times the odds of not being able
to afford the medication at all.
And you can see that the odds of having at least one of these five outcomes was over
three times greater among people who are severely food insecure.
Similarly, looking specifically at HIV care and management, so in a recent systematic
review from Singer in our group, we found a consistent association between food insecurity
and antiretroviral non-adherence in all but three of the 19 studies that we looked at.
And this was even after adjusting for socioeconomic status and other known barriers to adherence.
So in conclusion, we’ve seen that food insecurity and poor cardiometabolic health interact in
a vicious cycle.
Food insecurity worsens cardiometabolic health through several key pathways, and these include
worse mental health and stress responses, immune activation and inflammation, and changes
in health behaviors.
There are many points of intervention to interrupt this vicious cycle.
Interventions targeted to these pathways can really improve food insecurity and address
multiple health problems simultaneously.
Thank you very much.
DR. ANGELA ODOMS-YOUNG: That is excellent.
Thank you so much for these excellent presentations.
Now we’re going to move into our Q&A. We’ve already received a lot of good questions for
our speakers and I’m going to try to get as many as I can in the time allotted because
we shift to the break at 2:05.
The first question is for Dr. Abelev.
It’s exciting to see this shift to nutrition security, and I’m wondering how we can operationalize
this term.
We have found specific and consistent nutrient intake deficits in urban SNAP recipients,
these deficits confer an informatory burden that can promote chronic disease and immune
responses.
And so the question is figuring out how do we operationalize nutrition security?
DR. MELISSA ABELEV: Yeah, can you hear me?
DR. ANGELA ODOMS-YOUNG: Yes.
DR. MELISSA ABELEV: Yeah, okay.
Yeah, it’s a great question, I think one of the big things that...one of the important
things that we’ve done is the review of the Thrifty Food Plan, right?
In that, really looking at what does it take in order for people to have access to meeting
the dietary guidelines.
And so within the mathematical optimization model, the key factors that are the inputs
into the model are looking at the dietary guidelines and the food patterns, as well
as the dietary reference intakes and really saying, you know, what is it that families
need in order to be able to eat healthfully? And then aligning that with store scanner
data that is
from stores at the scanner level to go...to...sorry, inform the cost of the groceries, and
then ask when you align those things, what does it cost for a family to be able to purchase
a diet that aligns with dietary guidelines?
And so then by doing that re-examination, we see that it, in fact, necessitated an increase
in the SNAP benefit.
And so that reevaluation is a really key part there to say, do people have the resources
they need in order to access the dietary guidelines?
And so that’s a really key part when you overlay that, as I said, there’s a pretty
significant amount in the SNAP budget that goes out to the states, through community
partners, for nutrition education in order to help people know you have the resources
now, what is purchasing and preparing a healthy diet and making sure that people have the
information as well as communities have the resources for community-based PSE strategies
to say how do we help inform and shape an environment where people are able to access
healthy choices?
So those are the types of things.
And as I mentioned, some of the other policy things that USDA is pursuing through the WIC
390 fund, making sure that people know that they continue to be eligible.
As I mentioned, there’s a huge drop-off after the first birthday. We’ve done a significant
amount of research on retention and WIC and why people leave.
One of the key reasons is they don’t necessarily realize that they remain eligible.
WIC participants are also a very kind group of people.
And oftentimes they don’t realize that it’s not a pie, the people who are eligible can
continue.
And so they think, “Well, I don’t think I need it as much anymore and so I want to
make sure other people have access to it.”
So a key part of that is helping folks realize you both can be a part of it.
You don’t have to leave so that other people can get in.
And so those are the types of things that we’re looking at through the WIC 390 funds,
innovation strategies to make sure that people know of the resources that they have.
And then as I said, looking at SNAP online, WIC online, things that some of us take for
granted in being able to purchase groceries in many different ways, in ways that are convenient
to working parents and working environment and so forth, making sure that FNS participants
have access to those things too, so that it’s easy to access these important nutrition resources.
DR. ANGELA ODOMS-YOUNG: Thanks.
That actually leads me to a follow up question.
One of the questions that came in was about access to SNAP online.
What is the percent of participants that have a reliable access to online purchasing in
SNAP?
DR. MELISSA ABELAV: At this point, it’s 97 percent of SNAP participants have access to online purchasing.
DR. ANGELA ODOMS-YOUNG: OK, great.
Thank you.
I’m just looking through, there’s a couple of questions that came in related to Dr. Weiser’s
presentation about the pathways between food insecurity and cardiometabolic health.
There’s two questions—I’m going to kind of merge them together because they’re related:
Have these pathways been well established or are most of these studies cross-sectional?
And then a second question is related to the severity of the negative outcome in individuals
that have periods of food insecurity in life, but not consistent experiences of food insecurity.
So they may have more inconsistent periods where they’re food insecure vs. this
sort of persistent food insecurity.
So, overall, what do we know about these pathways?
Are they well-established in the severity of outcomes when people face different conditions
as it relates to food insecurity?
DR. SHERI WEISER: Thank you very much.
So, there's a...I presented a lot of different studies and certainly some of the population-based
studies I presented using the large datasets were cross-sectional, where we really...just associational
studies, so we can’t say much about causality in our work and there’s also a lot of longitudinal
studies out there where you are able to look at antecedents food insecurity, predicting
later cardiometabolic health.
And we definitely have found that earlier food insecurity is predictive of later health
outcomes.
So that may strengthen the plausibility of this association.
We also find, to the point of the intensity of food insecurity, that people who have more
severe food insecurity, we see dose-response relationships across so many of the studies
in our research and that of others where you see people with more severe food insecurity
have worse mental health problems, greater nutritional deficits, and greater...worse access to
care, greater acute care utilization and increased morbidity and mortality.
In terms of making the causal connection what we really need is intervention research, which
we’re going to be hearing more about.
But just as an example, in our research using medically tailored meals, working with Project
Open Hand, we found that individuals who received medically tailored meals had decreases in
depression and diabetes distress, improvement and adherence to treatment and care recommendations,
and reduced acute care use among other mechanisms.
And to your point about the sort of length, there’s sort of two more pieces to this.
To the points about persistent food insecurity vs. one-time food insecurity. And while we
haven’t evaluated this in our research over the long-term, we have evaluated it say, over
the past year, and we find consistently again, across our studies, that people who have persistent
food insecurity across multiple time points fare worse than people who just were food
insecure at one point in time.
And the last thing, just to clarify, is that we find food insecurity being associated with
both disease acquisition and then worse outcomes once people are impacted.
So for instance, with diabetes, we see worse adherence to treatment and care, higher hemoglobin
A1c levels and many other worse outcomes, and an increased morbidity and mortality.
DR. ANGELA ODOMS-YOUNG: Thank you so much, Dr. Weiser.
There’s several questions that came in for Dr. Coleman-Jensen.
The first question is related to the 2020 food insecurity prevalence estimates;
Are they available for specific age groups?
DR. ALISHA COLEMAN-JENSEN: In our annual report that presents all the statistics on food insecurity
in 2020 that I referred to today, we do include statistics for households that have elderly
members and households with children.
So we do break out those two age groups separately, but we don’t go into detail, across the lifespan
for each group.
And we typically find that food insecurity is somewhat lower than the national average
for elderly households and higher than the national average for households with children.
DR. ANGELA ODOMS-YOUNG: This is a question about the various surveys.
Does the food programs that are included in the surveys only include the federal food
and nutrition assistance programs or any food programs?
DR.
COLEMAN-JENSEN: It depends on the survey.
The current population survey of food security supplement, which is our source of federal
food security statistics that we report on annually, asks questions about use of community
nutrition assistance programs, such as food pantries and soup kitchens.
So it depends on the various surveys, what specific questions they ask, but some of that
information is available in the food security supplement.
DR. ANGELA ODOMS-YOUNG: And the last question, as it relates to the food insecurity data,
one of the attendees asked, "Why do you think the pandemic did not increase food insecurity
rates compared to 2019 food insecurity rates?
Was it due to expansion of SNAP and the provision of other resources?"
DR. ALISHA COLEMAN-JENSEN: I think more analysis is needed to understand fully the dynamics of food insecurity
during the pandemic.
We do know that in 2020, there were a lot of extra resources available to households,
both increases in nutrition assistance, as Melissa mentioned, and also increases in stimulus
payments, non-employment benefits, and the eviction moratorium.
All of those help to provide extra resources for families.
We know from previous research that increases in nutrition assistance and other benefits
do help to reduce food insecurity.
So it’s possible that, that was a factor during the pandemic as well.
DR. ANGELA ODOMS-YOUNG: Thank you so much, Dr. Coleman-Jensen.
We have a few additional questions that came in for Dr. Abelev.
The first presentation, you mentioned that over 800 flexibilities and waivers were created
throughout the pandemic.
With the creation of so many new guidelines, how was the information translated, for example,
to school districts, to ensure that they were educated?
DR. MELISSA ABELEV: Yeah.
We have a pretty mature communications channel to the local.
It’s called an SFA with the School Food Authority that are the...
for folks who aren’t familiar with the school meals programs, they’re run at the district
level through what’s called the School Food Authority,
and so we communicated that guidance to them in real time.
Essentially, as soon as it cleared, we sent it out through what’s called partner web,
out to the school districts, through our state partners, through our regional partners.
We also posted everything.
We had a commitment to try to post everything within 24 hours to our website.
And so every flexibility, every waiver, every adjustment was up on our website as well.
And so through multiple channels, we were trying to make sure that everybody had the information
in real time.
We also notify the Hill every time that we make a change, and so, those were also being
communicated out through congressional partners and such.
We tried very diligently to ensure that all operators had that information.
There were webinars that also, as things were happening, so that people could ask questions
and such.
So there was multiple channels.
DR. ANGELA ODOMS-YOUNG: Here’s a second question related to nutrition security and how it’s
being addressed in SNAP.
Dr. Abelev, can you talk a little bit about how the nutrition security piece is being
addressed throughout the SNAP program?
DR. MELISSA ABELEV: Yeah, and I think, as I mentioned, one of the key things that we looked at was in the update
of the Thrifty, really making sure that the resources were sufficient to really align
with the dietary standards and such.
And then the nutrition prevent...
Sorry...I’m going to stumble over my words.
The SNAP-Ed grant that we partner through part of a SNAP-Ed consortium throughout the
country, the Center for Nutrition and Policy Promotion, which is a part of the Food and
Nutrition Service and is in charge of the Thrifty Re-Evaluation.
They also lead the Dietary Guidelines for Americans Evaluation in partnership with HHS
every few years.
They also have the MyPlate dietary guidance and a number of nutrition education materials
through different apps and through different marketing materials so that...
the guidelines, which are highly scientific are then translated into messaging that is
focused on consumers and being able to understand how to purchase and prepare those foods.
So it’s through a multi-pronged effort through both the promotion activities we do at the
federal level, within our partnerships with states and local through those SNAP Nutrition Education partnerships and grants around the country.
DR. ANGELA ODOMS-YOUNG: Thank you.
One of the things that came out, Dr. Coleman-Jensen, in the data that you presented with
the focus on disparities and equity as part of this session, you talked a little bit about
some differences that you see in the 2020 data.
Can you talk a little bit more about that and maybe highlight...I know you can't, you don’t
have the reasons why, but I know both you and Dr. Weiser talked a little bit about some
of the pathways?
Can you talk a little bit about how and why you think some of these inequities exist?
DR. ALISHA COLEMAN-JENSEN: Sure.
Thanks, Angela.
We found that in 2020, food insecurity increased for all household with children, which I
mentioned.
Food insecurity increased for households with Black, non-Hispanic reference person.
Again, a reference person is sort of a survey term, but it’s an adult in the household
who’s name the housing unit is owned or rented.
You can think of a reference person as a head of households.
For a married couple or cohabiting partner, it can be either adult.
So households with a Black, non-Hispanic reference person saw a statistically significant increase
in food insecurity in 2020.
The higher prevalence of food insecurity for households headed by Black, non-Hispanic adults
and by Hispanic adults is a consistent finding over time.
Over time, we’ve seen that these households have higher food insecurity rates than households
headed by white, non-Hispanic adults.
There could be a number of factors related to these differences.
One is income differences across groups.
We know that poverty rates for example, are higher for these groups and our statistics
don’t account for differences by income or anything like that.
So, those are income differences and other disparities in wealth could play a role.
There’s also differences as others have alluded to, with regard to health disparities
across groups that may...that could possibly play a factor as well.
So as you mentioned, we can’t say for certain why food insecurity increased for some groups
in 2020 and not others, but there are a sort of lingering disparities across groups that
were not new this year, but that have been consistent over time.
DR. ANGELA ODOMS-YOUNG: Thank you.
There is a question specifically related to people with disabilities or with chronic conditions;
In assessing food insecurity, are they also assessing the relationship between disability
and food insecurity such as when a disabled or chronically ill individual may have food
in the house, but not the food they need, or might be unable to prepare or consume food
because of their disability.
DR. ALISHA COLEMAN-JENSEN: So we do...I can answer some of that.
So we do look at food insecurity by disability status, and we’ve done previous research
on that.
And when we have found that the disabilities are a significant risk factor for food insecurity,
households that include any adult with a disability have much higher food insecurity rates than
those that do not include adults with disabilities.
Primarily when we’re looking at food insecurity among adults or households that include adults
with disabilities, this again is related to economic resources.
In terms of...the definition of food insecurity doesn’t change when we examine food insecurity
and disabilities.
Of course, there may be a factor beyond income through which disabilities might affect food
insecurity.
One way to think about it though, is that if disabilities make food insecurity a problem
in part, because people with disabilities have more difficulty going to the store or
preparing meals or things like that, income may be able to overcome those challenges.
So if households are still experiencing those challenges, one underlying assumption is that
they don’t have the resources available to overcome, to pay for somebody to do those
things for them or to buy prepared meals and things of that nature.
But it’s certainly true that disabilities are an important risk factor for food insecurity.
And we’ve looked at...not disabilities across the range, the disabilities that are related
to employment in terms of people who are reporting that they’re disabled and are unable to
work.
Disabilities related to mobility, sensory impairments, and also mental health disabilities.
And all of those different types of disabilities are related to an increased risk of food insecurity.
DR. SHERI WEISER: And I just wanted to add one thing to that, which is just that several food security
programs and food delivery services really do take into account the role that disability
plays in a worsening food insecurity and nutrition security.
And so have delivery options of either medically tailored meals or groceries or prepared meals
in some other fashion for people with disabilities.
DR. ANGELA ODOMS-YOUNG: Thank you.
We have one question that just came in for Dr. Coleman-Jensen.
Dr. Coleman-Jensen had a slide that showed approximately 45 percent of food insecure
households did not participate in food assistance programs.
Do we know if they receive any support?
Could you talk a little bit more about this 45 percent that are not participating in food
and nutrition assistance programs or our federal food and nutrition assistance programs?
DR. ALISHA COLEMAN-JENSEN: Sure.
That’s a really important question.
And the caveat to that slide and those estimates is that those are self-reported survey data.
And we know that participation in federal programs is underreported as survey data.
So some percentage of those households may have been participating but not have reported
their participation.
Some households may choose not to participate for whatever reasons.
Some may be ineligible if their income is above threshold.
Or for example, if their household composition, if they don’t have children, they might
not be eligible for school meals of course.
And for WIC, depending on the composition of their households.
It’s important to note that the data can be underreported.
So I wouldn’t say that that’s a hard and fast percentage of...for sure that 45 percent
are not participating in those programs.
And I will say that research that’s able to account for selection into those programs.
So there’s an open question about, well, if all these people are participating in
nutrition assistance, why might they still be experiencing food insecurity?
But I think it’s important to note that research that is able to account for the self-selection,
into nutrition assistance programs shows that people who are, that participation in
those programs does help to reduce food insecurity.
And when I say, what I mean by self-selection is that people who really need the programs
are more likely to participate.
And if you really need those nutrition assistance programs, you may be experiencing food hardship,
right?
But we do find that when we’re able to account for that, for the selection into the programs,
that nutrition assistance does help to reduce food insecurity.
And especially when we examine the impact of the size of benefits, we find that the
larger benefits help to reduce food insecurity.
DR. SHERI WEISER: I wonder if I could add something there, and...which is basically that in our
research, we have also found that stigma and shame related to food insecurity, definitely
impeded participation, and another big factor in our qualitative work has been perceptions
of discrimination and structural racism similar to, in the health care setting in all federal
poverty and disability services.
People have reported experiencing similar things and that sometimes impedes their participation.
DR. ANGELA ODOMS-YOUNG: Thank you so much.
Thank you to the audience for such great questions and to our panelists for the thoughtful feedback
and responses.
We are going to take a quick break followed by a moderated network chat in the network
lounge. You have until 2:20 EST for the break and the chat discussion before the next session begins.
And so, I just, again, I would like to thank our speakers.
It was a phenomenal panel and really brought up-to-date information, both what has happened
since the pandemic started, as far as our federal food and nutrition assistance programs
responding, the current data, and then also understanding more about the pathways and mechanisms,
so we can understand more about the impacts of food insecurity.
And so thank you so much.
DR. ANGELA ODOMS-YOUNG: Welcome back.
We are going to start with session two, which is a state of the science regarding research
gaps and opportunities.
I hope you were able to take advantage of the moderating network chat.
As well as interact with colleagues, look at what's happening within the platform.
I know we've moved to this virtual world.
And so it's exciting that we have the technology to be able to interact.
So we're going to talk about the state of the science.
And the objective of this session is to discuss current knowledge of disparities and food insecurity,
and trends within respective demographic groups.
Describe the association of food insecurity with health outcomes and key drivers.
And then identify gaps in knowledge and research opportunities.
We are very excited to have Dr. Charlotte Pratt, program director at the National Heart, Lung,
and Blood Institute, who will serve as our moderator for this panel.
Her experience and expertise in nutrition and obesity research throughout the life course
will really help shape the discussion.
And so, Charlotte, I'm going to turn it over to you.
DR. CHARLOTTE PRATT: Thank you very much, Angela.
I'm really very delighted to be part of...
Thank you very much, Angela.
I'm really, very delighted to be moderating this session.
I also want to welcome everyone to this panel discussion.
In the previous session, our speakers discussed food insecurity in the context of food and
nutrition programs.
The USDA Nutrition Program, measurement of food insecurity, the pathophysiology of food
insecurity, and chronic diseases.
And now we'll be moving on to discuss disparities in food insecurity and highlight those groups
most at risk for food insecurity.
Our first panelist will be Dr. Craig Gundersen of Baylor University,
who will be speaking about food insecurity in often overlooked populations.
He will then be followed by Dr. Valerie Blue Bird Jernigan of Oklahoma State University,
who will discuss food insecurity among Native American communities.
Our third and final speaker for this session will be Dr. Lorrene Ritchie of the University
of California,
who will discuss food insecurity across the lifespan and the role of food insecurity among
pregnant women, children, and adults.
Please help me welcome our panel discussants.
DR. CRAIG GUNDERSEN: Good afternoon, everyone.
My name is Craig Gundersen. I'm from Baylor University.
I want to thank everybody very much for being here in attendance at this important conference,
and in particular, I wanted to thank Angela and Karen for giving me the opportunity to
talk with all of you today.
So there's a huge literature that's looked at food insecurity in the United States, you
know, literally hundreds of papers on this topic.
And it's pointed out a lot of different areas where people...there's different population
group that have higher or much higher probabilities of being food insecure than the general population.
But unfortunately, despite all this literature, a lot of these groups are still being overlooked.
So what I want to talk today about is food insecurity amongst these groups and these overlooked
groups.
So I could talk about, you know, five different groups, when we talk about this.
But then when you turn to is relatively a simple and straightforward solution to addressing
food insecurity and almost completely eliminate food insecurity amongst these overlooked groups.
But more broadly amongst the full population.
OK. So.
The first overlooked group is American Indians in our country.
The food insecurity rates are substantially higher than any other race/ethnicity group.
And I'm not going to talk much about them today because I know Valerie is going to be covering
the challenges facing American Indians.
This map is Feeding America's Map The Meal Gap.
Which has county-level estimates of food insecurity for all counties in the United
States.
All congressional districts are broken and also broken down by children and all households.
But when you look at this map is what you see as the standard stories high rates of
food insecurity in Appalachia.
High rates of food insecurity across the parts of the South.
One other thing that's most...that really points out the challenges facing American Indians
is if you look at a state like North Dakota or a state like Montana or a state like South
Dakota.
Overall, relatively low rates of food insecurity.
However, in these counties, which all contain American...American Indian reservations,
you find these incredibly higher rates.
Similarly, here in South Dakota, or looking at Arizona as these high rates of food insecurity
on the eastern edge of the state, which are where American Indian reservations are.
Or for that matter, looking at Alaska and Alaska Native communities.
So this is the first group with really high rates of food insecurity that are often overlooked
in our discussions about food insecurity.
The second group is black persons in the Upper Midwest.
There's been a lot of, and rightfully so, there's been a lot of attention regarding food insecurity
amongst black persons.
But oftentimes when people talk about this, they think about it like, "Okay, well, this holds
relatively similarly across the entire country."
That really is not the case.
Is what you see here is this is look breaking this down by census regions.
Okay?
So you have the Midwest, Northeast, South, and West for each of the groups.
For black, non-Hispanic, Hispanic, other non-Hispanic, and white non-Hispanic.
And these are for metro areas.
So we can see is the South actually has the lowest rate of food insecurity amongst black
persons.
Of any of the census regions, what really stands out is this.
And the Upper Midwest is you have these food insecurity rates.
Which are roughly 30 percent higher than any other region in the country.
And why is this?
This is probably through long histories of segregation in the Upper Midwest.
Whether it be in Chicago, whether it be in Detroit, whether it be in Milwaukee or Minneapolis.
Across the board, you see these long manifestations of segregation.
Which results in really high rates of food insecurity amongst blacks in those areas.
So, I think this is, again, a lot of attention being paid to the food insecurity amongst
black persons.
However, much less attention has been paid to the fact that this is mainly an Upper Midwest
phenomenon that we need to address in thinking about this. Okay?
The third group is young adults not in college.
Now, unfortunately, is that there was all this attention paid to quote, unquote
this college hunger across the country and was based upon some really poor and poorly done research
that showed these incredibly high rates of food insecurity amongst college students.
Which twice that of even most of the groups that were at the most high risk.
And so those of us who are experts in food insecurity...who do work in the food insecurity area.
We thought, of course, this work isn't valid.
I mean, nobody took it seriously.
But unfortunately, some in the media took it seriously, and even worse, some policymakers
took it seriously.
So, what I did is, I said, "Okay,
Well, what do the food insecurity rates amongst college students really look like compared
to the general population?"
What you see here is those college students who are full-time students.
The vast majority of college students are full-time students have rates that are much
less than the general population.
This line here in black. Okay?
So if every year from 2004 to 2018 lower rates of food insecurity amongst college students.
The main issue, though, is that there's amongst non-college students in this red line.
Is non-college students between the ages of 18 and 25.
Their rates are double those of college students.
So largely this whole thing about college hunger, it's not a myth.
I mean, some college students are food insecure.
But if we want to...if we're concerned with issues of equity.
It's we've got a lot more concerned about non-college students than college students.
They have much higher rates of food insecurity than college students.
And their rates are higher than the general population.
Unlike college students, which have really low rates of food insecurity.
So I think we need to take away the focus from college students who aren't at much risk
to non-college students who are young and facing serious risks.
That's the third overlooked group.
The fourth overlooked group is 50-59-year olds, Okay?
Is I think we really do need to concentrate a lot on food insecurity amongst seniors in
our country.
Okay?
This is the blue line here.
This is the food insecurity rate amongst seniors.
And this is derived from work that my amazing co-author, James Ziliak, and I have done over
the years to publish food insecurity rates for seniors in our country.
Recently, though, in work that we've been doing for food in America is, we've been looking
at food insecurity rates for those between the ages of 50-59, Okay?
And what do we see there?
We see that their rates of food insecurity are really high.
And substantially and quite higher than those in the 60-60+ age range.
So I think that this is another example where we have to...
there hasn't been much attention being paid to the 50-59-year-olds.
I think we should pay more attention to them given their higher rates of food insecurity.
And the fact that some of the things that are...are benefits for older Americans, which
are fantastic, like easier to get onto SNAP, Social Security, and other things aren't as available
to these individuals who are right below that 60-year-old threshold.
So we then we see that those 50-59-year-olds group is the fourth group.
Now the fifth and final group is the most important group that we need to spend a lot
more time talking about.
Okay.
The leading cause of food insecurity in our country today is disability status.
Really, nothing else even comes close to this.
So you can't talk about food insecurity without talking about disability status.
And in fact, one of the speakers at this conference is Alisha Coleman-Jensen has done a lot of really
neat work on disability status.
So she's probably not talking about that, but she's done a lot of neat work on this.
Okay, so what we see is that those with disabilities within a household is.
Could be a child with a disability, could be a parent with a disability, could be a
senior with a disability.
All these different dimensions.
So what we see is that those with households with disabilities have much higher rates of
food insecurity, especially those with mental health disabilities.
That even has a bigger impact on food insecurity than physical health disabilities.
Okay?
So is that what you could see here is that we're looking at the four groups I talked
about before.
This is broken down by percentage of persons, the food insecurity rate for those with disabilities
among American Indians.
So, you know, it's roughly you know, 14 percentage points higher.
Look at this, though, for 50-59 across the board,
non-college students, okay?
It's over twice as high for those with a disability than those without a disability.
Or looking at 50-59-year-olds look.
It's almost what's going on (INAUDIBLE) about four times higher for 50-59-year-olds with
a disability compared to those without a disability.
So we have to talk.
We can't really have a conversation about food insecurity in our country without talking
about disability.
So I want to say is that these five overlooked groups American Indians, black persons in
the Upper Midwest, Non-college students, 50-59-year-olds, and most critically, those with disabilities.
I encourage more research in this area and more ways to figure out policies to address this.
Okay?
So. Now, the good news is that it's straightforward and easy to end food insecurity in the United States.
This is not a difficult challenge to figure out how to end food insecurity in the United States.
So what I want to do is put forth, you know why it's so easy to end this.
Okay?
We have this amazing program in our country called SNAP.
Everybody in the audience is aware of SNAP.
And the advantage to SNAP is that it meets its central goal of reducing food insecurity.
Study after study after study has shown that SNAP leads to reductions in food insecurity.
This has become a stylized fact.
Now, the main reason it does this, there are several reasons why it does.
But I want to concentrate on one.
It gives dignity and autonomy to recipients.
Okay?
So many of the assistance programs in our country are demeaning or patronizing.
Including some food assistance programs towards those who are vulnerable.
SNAP doesn't do this.
SNAP says to recipients we trust you to make the right decisions with these benefits.
You can go to a store and shop alongside your neighbors and friends.
And the same way that they're shopping, make the same type of decisions that they're doing.
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
in our country by giving people dignity and autonomy
to make their own choices.
This is critical to SNAP being a successful program,
unlike some other programs.
So any discussion about SNAP...I'm sorry, about food insecurity and alleviate it has to begin
and end with SNAP.
There's no more important program.
So in a recent paper that I wrote in Food Policy is...
it looks at the issue is reconstructing SNAP as a universal basic income program.
And the way that this is structured is that every household would get the SNAP maximum
benefit level.
Okay, so this is the way it's structured is you know.
No phase-out with as incomes increases, every American would get the maximum SNAP benefit
level, okay?
And this would then be paid with taxes based upon the current distribution of income taxation.
For example, 70 percent of all taxes are paid well by most of us who are at this conference.
And that up to 10 percent of income in our country and over 97 percent is paid by those in the top half.
So in other words is this by paying for this expansion of SNAP is to be paid by those who
are already paying the vast majority of taxes in our country.
I first consider those paper SNAP as UBI but then I consider a modification.
The first is that probably people like myself really do not need SNAP, of course.
And so, therefore, as I said, Okay, well, suppose we cut off this with incomes up to 400 percent of the poverty line.
Okay? Roughly $100,000 for a family of four.
And so we say, OK, those above that income threshold will have to pay taxes to help support
this but they won't get the SNAP benefit.
The other thing is to increase benefits by $42 per week.
This $42 per week comes out of a study that two of my other amazing co-authors
John Pepper and Brent Kreider and I wrote basically showing that if you increase SNAP
benefits by about 25 percent.
Is that this would allow there to be a reduction in food insecurity amongst SNAP recipients
of about 60 percent.
And the good news is the USDA recently put in this large increase in SNAP benefits:
Maximum SNAP benefits between 20 to 25 percent.
It wasn't because of Brent, John, and mine's work.
But it is almost identical to what we are proposing.
By the way, for those of you interested, one of my other amazing coauthors is Elaine Waxman.
You're going to get to hear from her throughout this conference.
She and I have done some work looking at this topic along with Olivia Friel to see what
happens once benefit levels are increased and the profound impact that has on making
sure more Americans can afford enough food.
Okay, so that's just an aside.
However, is if I put both these modifications into this is that the impacts are profound.
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.
Okay? The cost of this would be roughly half a trillion dollars, okay?
You might say, "Oh, that's a lot of money."
Well, yes, it is.
But it's far less than what the combined stimulus packages from the Biden administration and
Trump administration had.
So in that sense, it's really not that expensive.
I pointed this out.
It's well to show that, look, this is we can eliminate food insecurity in the United States.
It's not hard to eliminate food insecurity.
It's not cheap to do so, but we definitely could do so.
And even if this program like this is not implemented.
At least it gives us a guide to be able to say, okay.
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."
Okay? So again, SNAP is an amazing program. Let's make it even more amazing in our country to completely eliminate food insecurity.
And in particular to eliminate food insecurity amongst these overlooked groups that I've
talked about in this presentation.
Thank you very much. Enjoy the rest of the conference.
DR. VALERIE BLUE BIRD JERNIGAN: Hello, I am Valerie Blue Bird Jernigan.
I am a professor of rural health at Oklahoma State University, where I direct the Center
for Indigenous Health Research and Policy.
And I'll be speaking with you today about food insecurity among Native American communities.
I want to share a bit about the historic roots of food insecurity among Native Americans.
Shown here you see a photograph taken of a ration ticket issued in the mid-1880s
to a member of the Oglala Lakota tribe on the Pine Ridge Reservation in the southwest
corner of what is today South Dakota.
The number nine here indicates this person was allowed to draw rations of beef.
And also when available beans, corn flour, salt and occasionally sugar, coffee, soap,
and tobacco for nine dependents each Saturday.
These rations were provided to Native people because their traditional foods buffalo specifically
in this Tribe had been decimated.
And these rations were provided to them to prevent them from starvation.
So the roots of food insecurity among Native people are deep.
And when we study food insecurity among Natives, we cannot separate out that history of displacement
and removal from traditional food systems to restricted reservations which altered our
dietary patterns and had repercussions for our modern food systems and environments.
I'm providing an overview of existing knowledge on this topic, and there has been relatively
limited research conducted on food insecurity and Natives.
Most studies rely on small or regional samples.
In 2013, my colleagues and I looked at California Health Interview Survey data.
And we found that 38.7 percent of natives with incomes below 200 percent of the federal poverty level were food insecure.
Another study of a reservation sample in Montana found 43 percent of households surveyed were food insecure.
And in our recent Thrive Intervention study in rural Oklahoma, we found 60 percent of Natives
were food insecure.
We also found that the prevalence of obesity and diabetes and hypertension was higher among
those who were food insecure compared to those who were food secure, even after adjustment
for age, gender, study site, education, and income.
We also looked at the current population surveys, food security supplement data.
And we analyzed food insecurity trends among Natives compared to other racial and ethnic
groups in the U.S. from 2000 to 2010.
We found that 25 percent of natives remained consistently food insecure during that time period.
Natives were twice as likely to be food insecure when compared to whites.
And in this sample, urban Natives were also more likely to experience food insecurity
then rural Natives.
My colleagues and I recently formed a small group we call ICHANGES.
And this stands for Indigenous Collaborative for Health Agriculture Nutrition Growers and
Environmental Sovereignty.
This group was developed to better understand food insecurity and ways to address it among
Native communities.
We conducted a scoping review this year.
We looked at food insecurity among Natives and how it relates to other socioeconomic
factors and nutrition and health.
And this particular work was led by Dr. Cassandra Nikolaus at Washington State University.
For the scoping review, we conducted a systematic review using PubMed.
Three investigators independently screened the results.
And each study that included quantitative food insecurity data was assessed for quality
by two independent members of the research team.
We used six criteria to assess quality based on the Methods Guide for Effectiveness and
Comparative Effectiveness Reviews.
We found a total of 34 reports that described 30 studies that were included in our final
narrative synthesis.
Most of the studies 73 percent were cross-sectional.
The weighted average prevalence of food insecurity was 45.7 percent though estimates varied from 16
to 80 percent.
Food insecure households had higher intake of sugar-sweetened beverages and fried foods
among children and adults.
They had poorer nutritional health and risk.
Transportation barriers were common in food-insecure households.
They had long distances to food retailers, and they consumed low amounts of fruits and
vegetables.
Studies identified food preservation and gardening across familial generations as a key opportunity
to not only ensure food security but also to provide financial income.
And acknowledging the meaning and value of traditional foods and their role in promoting
food security.
And food sovereignty was something that several of the studies cited as being important to
Native communities.
There was also more research being called to capture and address the unique characteristics
between rural and urban Native communities.
About 70 percent at this point of Native people live in urban areas.
And so we need to know a lot more about urban Native communities and food security in those
areas.
I'll transition here to solutions.
As an interventionist, my work focuses primarily on research that seeks to reduce and eliminate
food insecurity.
To address food insecurity in Native communities we're focusing on food sovereignty.
Which I've defined here using one of the more common definitions.
And it's really the right and for Native peoples.
The responsibility of Native people to healthy and culturally appropriate foods.
So it's a food system in which the people, in other words, the people who produce, distribute
and consume food, also control the mechanisms and policies of food production and distribution.
This is opposed to what we currently have the corporate food regime,
where corporations and market institutions control the global food system.
Native food sovereignty adds not just the right, but also, as I said, the responsibility.
Because in Indigenous cultures food is considered a sacred gift.
And we have responsibilities to take care of the land and water and ecosystem that produces
those gifts.
A primary difference between food security and food sovereignty is that.
Food sovereignty focuses on restoring the connection Indigenous people have with their
food systems and land.
And not just the provision of food to poor communities.
The food sovereignty approach emphasizes source and connectedness and sustainability.
And therefore interventions that are guided by a food sovereignty model are much more
likely to facilitate long-term systems change.
I included this model from the Council of Canadian Academies because I really like it.
It highlights the dynamic relationship between food security and food sovereignty and the
factors that influence both of these concepts in Native communities.
As we see food security is connected to colonization and environmental change and the economic
well-being of communities.
And those factors have to be considered when we are intervening on food insecurity and
all of the associated health outcomes.
Food sovereignty as this model depicts can be thought of as a way to facilitate food
security.
And this is my last slide, I just want to emphasize we are actively implementing food sovereignty
interventions in Native communities.
We are intervening, my research group and others, multiple levels of the food system,
to create long-term healthy food access and food security.
I've included a couple of pictures here from several of our studies.
Our THRIVE study intervened and it just ended this past year.
THRIVE intervened to create healthy makeovers in Tribally owned and operated convenience
stores.
And this was in the Chickasaw and Choctaw Nations of Oklahoma.
And it increased healthy food purchasing and access and had no risk on the bottom line
of these convenience stores.
It actually increased the revenue of the stores.
We are currently implementing the FRESH study with Osage Nation, a farm-to-school intervention,
which supplies nine Tribal Head Starts.
And the families whose children attend those Head Starts with produce from a Tribal farm
that was developed in tandem with this study.
And most recently, a community-supported agriculture study also with Osage Nation.
That expands the farm-to-school intervention to a community-wide study of this community-supported
agriculture initiative and its impact.
We're going to study its impact on food security, BMI, hypertension, and A1c levels.
So it can be done.
And we're seeing really exciting changes.
Our work was also featured in the Blood Sugar Rising documentary that was recently released
by PBS.
That's why I have this picture up here, Blood Sugar Rising.
So check that out, and I'm now happy to take your questions.
Thank you.
DR. LORRENE RITCHIE: Good afternoon, I'm Lorrene Ritchie, the director of the Nutrition Policy
Institute at the University of California's Division of Agriculture and Natural Resources.
At NPI, we conduct Public Health Nutrition Research to inform programs and policies to
improve food insecurity among children and families.
And I'm going to be talking today about factors associated with food insecurity across the
lifespan.
Because my own research focuses on children, to prepare for this talk, I turn
to the published literature, and I started with Craig Gundersen and James Ziliak's 2015
review article on Health Affairs, which summarized research on the impacts of food insecurity
published since 2001.
As you can see from this slide from a basic PubMed search, publications on food insecurity
in the U.S. have increased dramatically since 2015.
So, what I will summarize is my take on the evidence building upon Craig's excellent review
by adding findings from more recent reviews and studies.
Please note, though, it is not a comprehensive, systematic review or meta-analysis, but more
of a scoping review.
So, please forgive me if you don't see any of your studies or others you know about cited
here.
In the next few slides, I'll summarize where evidence exists, as well as where I see gaps
and opportunities with respect to impacts of food insecurity across the lifespan.
As Craig highlighted earlier in this session, disparities in food insecurity exists across
the lifespan.
In addition to the most obvious risk factor poverty, higher prevalence of food insecurity
is associated with lower educational attainment being a racial or ethnic minority, housing
instability, households with children, especially when run by single parents, women, younger
adults, and seniors living alone.
These are all populations with high risk of food insecurity, as are those listed on the
right-hand side of this slide.
Next, let's turn our attention to the evidence on the impacts of food insecurity from surveys
that, for the most part, control for those risk factors I just named, and we're going to
start with pregnant and breastfeeding women and infants.
And as you can see from the factors listed on the left of this slide, there's considerable
evidence to support an association between food insecurity and higher pre-pregnancy weight
and obesity, excess or inadequate gestational weight gain, fewer prenatal health care visits,
pregnancy complications, and health, mental health issues, smoking exposure.
And in terms of infants, premature births, birth defects, developmental delays presenting
to the emergency room, less immunizations and lower breastfeeding duration.
Topics, I think represent gaps and opportunities for further research on this life stage are
shown on the right.
And interestingly, while it is well-established for individuals and other life stages, as
you're going to see that food insecurity is related to the consumption of poor diet quality, typically
characterized by more low-cost, higher energy-dense foods.
During pregnancy, lactation, and in infants, the evidence associated in food insecurity
and diet quality is just not as consistent.
Other gaps in knowledge include the relationship between food insecurity and breastfeeding.
There's some lack of consistency with respect to breastfeeding, with some studies showing
impacts on duration, but not initiation.
Subsequent pregnancy and barriers to contraception is also a gap.
A recurring theme you're going to notice across the life stages is the need to better understand
longer-term impacts, and whether there are critical stages in a lifespan where those
longer-term impacts are more profound or detrimental, also applies to infants and during pregnancy
and lactation.
Gaps on birth weight and infant adiposity impacts and weight status later in life and
later child development.
And then finally, an emerging area of research has to do with whether parents and other caregivers
change how they feed infants and older children as well in the context of food insecurity.
And interestingly, the evidence is building that there may be a connection.
For example, Grosz and colleagues in 2018 in a sample of low-income Hispanic households
found that prolonged food insecurity during both pregnancy and postpartum was associated
with greater maternal pressuring of infants to eat.
Swindell, in a 2020 study, found that preschool and early care and education teachers that
were food insecure were more likely to use authoritarian feeding styles, another feeding
practice that is associated with child obesity.
So, an interesting area for further research.
For children and adolescents, there's evidence that food insecurity is associated with multiple
impacts.
Diet quality, nutrient intake, and iron deficiency anemia are impacts shown in the research.
Asthma, high blood pressure, dental problems, hospital visits, early menarche, and obesity
especially in older children and girls.
Regarding obesity, there are some newer studies suggesting some possible mechanisms besides
parent feeding practices, which I mentioned earlier.
For example, Delvecchio in a 2020 study found that parents in food-insecure households were
more likely to identify their child as underweight, even though they were normal weight than parents
in food secure households.
West and colleagues in a 2021study found food insecurity moderated the positive association
between low income and loss of control of eating among adolescents.
Unhealthy weight control practices and body image, sleep quality, parental report of poor
health and developmental delays, these are additional impacts well supported by the literature.
Moving on to suspension and expulsion in school on behaviors, absenteeism, academic performance
and mental health problems and even risky behaviors have been shown to be associated
with food insecurity among adolescents, such as failing to get money for food.
In terms of gaps, we need more longitudinal studies on the long-term impacts and whether
these differ by child age.
A case in point in a longitudinal study published in 2020, Xu and colleagues found that food
insecurity in the third, fifth, and eighth grades was associated with obesity concurrently
or in later grades.
But food insecurity in kindergarten was associated with underweight.
In another study published in 2020 by Gomber and colleagues, they found that food insecurity
in early life was associated with lower BMI in ages 2 to 3.5 years, but increased BMI
3.5 and older.
Again, suggesting potential differential impacts of food insecurity over time.
Gender differences are not always observed.
But when they are, as I pointed out, food insecurity tends to have greater impacts in
girls and women compared to boys and men.
But how these differences relate to gender norms versus biology merits additional study.
Eating disorders, you know, not all studies have shown a consistent relationship between
food insecurity and disordered eating.
A recent study by Eagleton in 2021, for example, found that household food insecurity was associated
with higher food responsiveness in children as young as 3 to 5 years old, but only
when parents reported high levels of stress and low levels of family functioning, which
leads to our next gap.
And that is how other adversity relates to food insecurity.
Most studies aren't able to capture the details on all the elements of a person's family or
community context or social capital, and how this influences their experience and impacts
their food insecurity.
Interestingly, also, most of the existing literature is deficit focused, measuring what
factors increase food insecurity, but not what protects children from food insecurity.
And finally, there's a need to identify an optimal food insecurity measure for children.
Most study to date of child impacts, based food insecurity on parent report and parents
tend estimate their children's food insecurity experience.
Fewer studies have used the USDA's module for ages 12 and up.
Freeman Frangela in 2013 did some excellent qualitative work with children to develop
the Child Food Security Assessment tool that can be used with children as young as eight
or 9 years old, and assesses not only the cognitive and emotional physical awareness
of food insecurity, but some actions children might take.
This and other child focused assessments merit further use and investigation in relationship
to child impacts.
Associations have also been examined among young adults, with most studies focusing on
college-aged students.
Again, we see impacts of food insecurity and diet quality, cooking skills, disordered eating
and eating disorders, academic performance, mental health, social isolation, physical
health and chronic disease, smoking, substance use, sexual risk, sleep and obesity and specific
to students financial health, such as accruing student loans and debt.
In terms of gaps in knowledge and this applies, really, to all stages of life.
Physical activity is not.
There are some studies that have shown association, others that have not.
And again, long term impacts on diet, weight and health and economic well-being.
For other adults where there appears to be the largest increase in studies, we see most
of the same impacts as for younger adults.
However, we're now seeing greater impacts on morbidity from diabetes, cardiovascular
disease, end stage renal disease, chronic obstructive pulmonary disorder and cancer,
as well as early death, including from intentional injury and suicide.
In terms of gaps, some new insights have emerged in recent years that merit additional research.
For example, Nettle, in a 2019 study using NHANES data, found food insecure women had
less varied amounts of food and more variations in when they ate.
Factors which in other studies have been associated with potential risk of obesity.
Work performance is a gap in our knowledge.
And physical activity again, and racism.
A 2019 study in Philadelphia found that among Latinx and black mothers, their experiences
of discrimination in schools, a child or in the workplace as an adult were associated
with higher odds of food insecurity.
Traumatic life events in the larger context of family and community, I mentioned earlier.
In several studies women exposed to childhood abuse and violence later in life were more
likely to report food insecurity.
And some people had found in qualitative studies that women described the impact of adverse
childhood experience on their school performance and ability to meet and maintain employment,
and then that experience negatively affecting their child, their own children's food insecurity,
suggesting intergenerational impacts.
Finally, related to later topics of this workshop on the food, environment, Janda and et. al.
in 2021 in a study done in Texas found that urban and rural adults living in zip codes
that only had supermarkets in neighboring zip codes were more likely to seek help with
food compared to those that had supermarkets locally, suggesting some larger context that
we need to better understand.
Last but not least, let's turn to older adults seniors age 60 or older.
Many of the studies featured in the slide I just showed included older populations.
But the studies cited here provide some unique impacts related to older adults, such as physical
strength and mobility limitations, activities of daily living, social isolation and cognitive
function and mortality.
In terms of unique gaps, Gunderson and Luria in 2012 in a workshop for the American Society
for Nutrition identified the impacts of food insecurity on seniors as a gap.
And nearly a decade later, I think we filled some of those gaps, but there's still some
remaining.
In addition to some that I already mentioned on the previous slide, ability to live independently
and stigma.
Pack and Kim in 2020 found that SNAP reduced the association between food insecurity and
physical health in seniors, but not mental health.
And they hypothesized that there's stigma associated with food insecurity may have reduced
seniors' self-esteem, increase their risk of depression.
And while I haven't mentioned stigma previously, stigma is important outcome to assess across
the lifespan in relation to experiencing food insecurity.
And to participate in the programs designed to address it, which leads us to the next
and almost last slide of mine, which is one of the things that makes it difficult to distinguish
the causes and effects of food insecurity has to do with what's called the cycle of
poverty depicted here.
In other words, poverty may lead to nutrition impacts, such as food insecurity and poor diet
quality.
But these, in turn, may lead to mental health issues, school and job performance, risk taking,
obesity, a lot of physical health ailments.
And all of those, in turn, may lead to lower wages and less employment and higher health
care costs, which then lead to more poverty and the cycle continues.
But food insecurity doesn't always begin with poverty, and it's clear from this figure that
one could jump into this cycle at multiple places because of multiple other insults and
at multiple times across the lifespan.
So one of the things that we have in place in the United States is to provide assistance
at various points along the cycle.
And some especially innovative ones will be shared in the next session.
But some of the examples of more traditional approaches include income assistance, such
as TANF nutrition assistance, such as SNAP, Education Assistance, such as Universal pre-K
and Pell Grants, Health Care, Medicaid, Job Assistance.
But what we have learned from qualitative studies is that there are many barriers to
assessing each program, even when adjunctive eligibility, for example, is in place.
And that unintended stress, stigma and shame can potentially result.
And those who most need the assistance, may have the least time, resources and ability
to navigate these multiple programs.
So I'm posing to the group, is it time to rethink how we provide services not just for
food insecurity because some other times, as I mentioned, food insecurity is a symptom
of other issues that we alone will not fix.
So instead of each program operating independently, could there be a more cohesive way to support
people cradle to grave in accessing services needed?
In short, I think the biggest gap in research is that we need to better understand how to
effectively disrupt this cycle.
In summary, in terms of research gaps and opportunities, they include the need for more
longitudinal studies.
There have been more recently, which is great.
But more are needed as it's tricky to disentangle these likely bi-directional relationships.
Food insecurity can occur at any point throughout life, but consequences may be more severe
in some stages and under certain circumstances and we need to better understand those.
Are there intergenerational impacts?
How do we consider the impact of food insecurity in relation to other life events.
And most importantly, not just deficits but assets.
And finally, how do we best break the poverty cycle across all life stages and intergenerationally
and ultimately prevent food insecurity before it happens?
With that, I'll turn it over to our moderator to entertain questions and ideas from the
rest of the group.
Thanks.
DR. CHARLOTTE PRATT: Thank you, all, very much for these excellent presentations.
We have quite a lot of questions here.
I think these presentations really draw attention to the need for a targeted approach to food
insecurity to make people become food insecure.
An American Indian population aged-population between 50 to 59, as well as others who are
disabled and African-American populations.
A few questions have come in and I'm going to go through the list as we have received
them, particularly paying attention to questions that are fairly relevant to the topic at hand.
So, let's see.
While I'm waiting for this to come on.
I'm going to...
DR. CRAIG GUNDERSEN: I can see the questions.
DR. CHARLOTTE PRATT: Yeah, hold on just a second.
DR GUNDERSEN: Yeah, definitely.I can read those ones.
DR. CHARLOTTE PRATT: There's a question that came on about for Dr. Gundersen relating to
homelessness and Asian population, why you don't have any studies, whether you have any
studies on that, if you can comment on it.
DR. CRAIG GUNDERSEN: So, the first thing is in looking at overlooked groups, I only had 15 minutes
to talk, so this is part of the reason why I couldn't include all groups and I just concentrated
on those groups.
Definitely, you know, the homeless population in some ways has higher rates of food insecurity.
And there's been some work done in that population, but we could do more work with that group.
I mean, oftentimes...
So there hasn't been enough work and more work to be done on this.
Asians, amongst Asian-Americans, this is somewhat of a tricky issue insofar as on average American
Indians have the lowest rates in the United States, far lower than white non-Hispanics.
The problem, though is that there's a lot of Asian groups with very high rates of food
insecurity that are often overlooked.
So, for example, the Hmong population has very high food insecurity rates in the United States,
as do Afghani-Americans have very high rates.
So in other words, there are certain segments of the Asian population that have higher rates,
and we should be talking about those.
Even if overall rates of food insecurity amongst Asian-Americans are the lowest of any ethnic
or racial group.
DR. CHARLOTTE PRATT: Yes, thanks for the response there.
There's another question here about how can SNAP be even more amazing by ending food insecurity?
And I do recall that your values are very similar to what the Thrifty Food Plan showed.
And so if you could elaborate on this comment here; What are some next steps you would recommend
to make SNAP even more amazing?
DR. CRAIG GUNDERSEN: The first thing I recommend is getting rid of this terminology nutrition
security.
Let's just get that out of the conversation.
It's a way of blaming vulnerable households for their own...for what they eat and everything.
It comes from groups...generally from groups of people who want to criticize those who
are vulnerable in our country.
Plus, there's no accepted way to define nutrition, insecurity and stuff.
And it's also there is nutrition insecurity across the full income spectrum.
I really dislike this term.
I think we need to keep talking about food insecurity.
Let's set that aside, though, let's talk about food insecurity.
This is not about nutrition.
Nutrition insecurity make that.
But let me then talk a little bit about how we can make SNAP even more amazing is to make
SNAP such that you would expand out eligibility for the program in some work that we've done on
this is expanding eligibility even out to the case that I proposed in food policy, which
dramatically reduced food insecurity because you have so many people who are slightly above
the threshold for gross income eligibility that are food insecure.
So bumping that up.
And similarly, is expanding benefit levels...increasing benefit levels akin
to what the USDA did, just increasing those benefit levels.
So I think all this is great to reduce food insecurity.
Let's continue to talk about food insecurity until we've eliminated food insecurity.
And let's stop, stop, stop talking about nutrition insecurity as long as we still have food insecurity.
DR. CHARLOTTE PRATT: Thank you.
Another question relates to the overlooked group the 50 to 59 year old's experience much
higher rates of food insecurity.
But how about the 60 plus?
Do they have access to more benefits compared to the 50 to 59?
DR. CRAIG GUNDERSEN: So, I mean, part of the...part of the reason why I...
But before turning to that, I think there's also some questions for Valerie and Lorenzo
if we could get some of those.
So in terms of why the 60 and above population, there are a few things that are different.
First of all, they're oftentimes eligible for like income support programs or Social
Security, SSI and things like that.
So that helps.
The second thing that those who are in this older group is, is that the eligibility for
SNAP is made easier for those who are over the age of 60, not something for 50 to 59.
So this is why I think that there are things that are available with 60 plus group that's
not available to the 50 to 59 group.
And so I think that, you know, based upon some early work that again, James Ziliak and I did,
is we showed that the 50 to 59 age group actually has the lowest participation rate in the SNAP of any group.
So let's figure out ways to help them out more.
DR. CHARLOTTE PRATT: Thank you. I have two questions for Dr. Jernigan, and I think two for Lorrene as well.
So, this person wants to know about...said, "Thank you for your insightful talk, Dr. Jernigan. Can you educate us further on the language?
I noticed that you used Natives to refer to American Indian and Alaskan Natives throughout your talk.
Is this the descriptor preferred by these communities?"
DR. VALERIE BLUE BIRD JERNIGAN: Hi, there.
It really is hard to answer that because there are over 565 federally recognized Native nations,
sovereign nations in the U.S., each with their own terminology, languages, names.
So, it really depends on what the preferred terminology is for each of those communities,
those nations, those groups.
A lot of folks use American Indian and Alaska Native because it is used in the treaties.
And so there's a preference in some areas for that language with that terminology.
But other folks prefer Indigenous or Native American.
It really is up to the individual and individual community what their preferences are.
DR. CHARLOTTE PRATT: Thank you very much.
There's a question here about your scoping review, and if you could kindly provide the...
Oh, what's happening?
If you could kindly provide the (INAUDIBLE).
[Audio Cuts Out]
DR. VALERIE BLUE BIRD JERNIGAN: Hi, there. It is actually not yet published. It just actually went in for publication today.
But I wanted to share a little bit with you of what we found.
DR. CHARLOTTE PRATT: Thank you.
I think I'm getting an echo here.
So, there's a question here for Lorrene.
"Excellent and comprehensive presentation.
I am wondering if you came across any information about food insecurity among households with
children with food allergies?"
DR. LORRENE RITCHIE: Yeah, that's a great question.
I do recall seeing one paper, which I did not include in my review and presentation.
And I do see you asked that question and I'm happy to share that I can't recall
the details of that paper, but I will definitely share it with others.
DR. CHARLOTTE PRATT: Thank you.
I think we will be able to do that in the on demand and when we post it, so that will
be available.
Another question for Lorrene:
"Thank you for this great overview and potential research opportunities.
Are there open data sources with both food insecurity and health outcomes that we can
use for looking at the effect of non-static during the life course?"
DR. LORRENE RITCHIE: Yeah. So earlier we had a talk by Alisha Coleman-Jensen that talked about some of the sources
of data that include the NHANES, for example, and the community CPS survey.
But all of those open source data sets, which do include to various extents measures of
food insecurity and health outcomes are at one point in time.
So one of the things that I think we need to think about as a field is how we can follow
people longer longitudinally.
There are some longitudinal data sets out there, and I did include some of those in
my presentation of the literature.
But most of the time, they follow people for a small percent, a small part of their lifespan,
not across multiple stages of their lifespan.
So that's definitely an area for future research.
DR. CHARLOTTE PRATT: Thank you.
Dr. Jernigan, there's another question for you here;
Thank you for the wonderful talk.
Can you please talk about ways to improve the food distribution program in American
Indian reservations, or how to replace it with (INAUDIBLE).
DR. VALERIE BLUE BIRD JERNIGAN: Sure. As a recipient of it myself, when I was a kid growing up here in Oklahoma, I
can tell you that it used to be a really different thing than it is now.
It has gotten a lot better.
The FDPIR program has made significant changes in the last decade or so.
But it still has a way to go and we still see a lot of differences across regions.
It's very, very hard to get refrigerated trucks to deliver a lot of the fresher produce to
some of the more isolated reservations.
And so that's a big thing that we've worked on.
Some of my worked in very rural parts of California looked at that.
We need equity around access to refrigerated trucks, repeated deliveries, much more frequent
deliveries.
There has been a lot of advocacy at the community level to improve the FDPIR and to include
more options, fresher options.
And a lot of that advocacy has come from Tribal leadership and Tribal community members.
And so I would say continue the advocacy.
I would say we need more studies that focus on improvement, particularly over time and
the association with help.
And I think looking at the sort of inequalities within inequalities.
And so, are there greater disparities in some regions vs. others?
Those are the things that we need to focus on in FDPIR
And so we need more research and we need more advocacy.
DR. CHARLOTTE PRATT: Thank you very much.
There's a question here again for Dr. Ritchie.
This question missed some parts of your presentation.
But she was wondering whether there are some data presented for early exposure of adversity
in relation to chronic disease in later adulthood.
So, tracking from early exposure and then looking at the trajectory of food insecurity
into later adulthood.
DR. LORRENE RITCHIE: Yeah, I mentioned a few studies about that.
Happy to share more.
But yes, we are starting to see emergent data suggesting that early childhood adversity
has impacts both on the individuals who experienced that adversity as adults increase food insecurity
among themselves as adults, but also some potential impacts on their ability to provide
for their own children.
And the suggestion that there may be intergenerational impacts.
Again, I put those on this side of the literature of where we need more research and more folks
at looking at those impacts.
Those are much harder studies to do.
I know for myself, you know, that kind of longitudinal look requires a lot more funding.
But perhaps that something NIH and USDA can help us with as researchers so that we can
answer some of those intergenerational impact questions.
DR. CHARLOTTE PRATT: Alright.
So thank you all very much.
I think we are out of time now.
And thank you for all your questions.
Certainly we aren't able to answer all of them, but we'll make sure that these questions
are posted somehow.
So we'll take a few minutes for a break and then come back to the next session.
Again, thank you very much.
DR. MARLENE SHWARTZ: So, hello, everyone, I'd like to welcome you to the panel.
The next two flash talk sessions will include eight minute presentations that highlight
innovative interventions.
And our first panelist is Dr. Caitlin Caspi of UConn's Rudd Center for Food Policy and
Obesity, my colleague and she will share her work exploring the influence of increasing
minimum wages on food insecurity outcomes.
The next flash talk is Dr. Amy Yaroch of the Gretchen Swanson Center for Nutrition.
She will share Early Results from the Gus Schumacher Nutrition Incentive Program GusNIP and produce-Rx.
And last we'll have Dr. Lisa Harnack, who will discuss the Restrictions and Incentives in the Supplemental Nutrition Assistance Program, or SNAP.
So, why don't we get started?
DR. CAITLIN CASPI: In today's presentation, I'm going to be discussing minimum wage increases
as an opportunity to address food insecurity.
I'm going to focus this talk on a specific evaluation that I'm leading—the Wages Study—which is
an NIH-funded five-year study that looks at whether minimum wage increase affects diet-
related outcomes, specifically food insecurity, food purchasing and body mass index among
low wage workers compared to a control community.
So, why are we discussing minimum wage in relation to diet-related health?
Isn't it too far upstream for a direct effect?
Aren't there other public policies that are more directly going to work on behavior?
Well, yes, and there's going to be plenty of discussion about those policies, I think in
this conference.
But minimum wage really can be powerful to consider for a number of reasons and I think
it's especially powerful in combination with some of the other policy interventions you're
going to hear about, as well as additional interventions at other levels of the social ecological model.
So, what's important to think about with minimum wage?
First, it's a key social determinant of health, and like many SES indicators, there's evidence
that it's associated with a range of positive health outcomes, from birth outcomes to all
cause mortality.
Minimum wage can affect diet and diet-related outcomes through multiple pathways that I'm
going to be walking through in just a couple of minutes.
And finally, minimum wage is a potential policy lever to address health equity.
So, unlike some policies that span the socioeconomic spectrum, minimum wage laws are really going to
be impactful for low wage workers, black and Hispanic workers, those who represent really
the greatest risk for diet related disease.
It's also important to study minimum wage right now because it's modifiable and it's
pretty high on the political agenda.
We're seeing a lot of states increase their minimum wage above federal levels, and we're
seeing local jurisdictions, counties and cities increase their minimum wage.
And we're also hearing about businesses like Amazon and Target and Costco that are raising
their minimum wage to $15 an hour or even above.
So, this is the hypothesized relationship between minimum wage and the outcomes that
we're looking at in measuring in the wages study.
So, we're doing annual surveys, getting pay stubs, doing height and weight and collecting
diet receipts or food purchasing receipts among our participants.
And what we really think we're going to see is that increased minimum wage is going to increase
household income, which is going to have a net positive effect on diet quality and other
obesity-related outcomes.
So, this study is designed as a natural experiment where we're following workers that have been
recruited in two different cities Minneapolis, Minnesota has a minimum wage ordinance under
way where they're raising minimum wage.
The city is incrementally to $15 an hour until 2023.
And the comparison community is Raleigh, North Carolina, where there is a state preemption
that prohibits the local jurisdictions from increasing their minimum wage.
And so in that sense, it makes a good control site.
And it also makes a good control site because it actually has a fairly similar set of demographics
to Minneapolis, except that it does have a higher proportion of black residents.
So, for the study, we recruited workers who were making less than $11.50 an hour in both
cities.
It was a community-based sample and we're still in the midst of data collection and
we'll be following these same participants until 2022.
And at the end of the study, we're going to do a difference in different analysis to look
at change in the outcomes across the two cities.
So, while the study is still underway, I would... just wanted to present some descriptive statistics
from our first three time PAC points from 2018 to 2020.
The average hourly wage of study participants was slightly higher in Minneapolis at baseline,
but it did increase in both of the cities in the two subsequent years.
So, now we're looking at food insecurity in the two cities, which was very high at baseline
using the six-item USDA measure, it was more than 70 percent at baseline in both cities.
And it did decrease in both cities in 2019 and then again in 2020.
And this difference was not statistically significant between cities and it's still
high, but not as high as at baseline.
This is looking at SNAP participation, which we know that many of our participants were
relying on.
It did appear to go down slightly between 2018 and 2019 and then went up again in both
cities during 2020, which is perhaps not surprising given that we know that access to SNAP and
eligibility for SNAP participation did change during the pandemic, which tended to make
it more accessible to people.
So, we know that many of our participants were relying on both resources from their
income, as well as food assistance resources to make purchases and to put food on the table.
And in 2019, we conducted a qualitative study to dig into this a little bit more among 112
of our wages study participants and we found a number of themes.
I'm just going to highlight two of them.
The first is that when we ask people about their SNAP benefits, they so commonly talked
about SNAP really as just one part of the overall safety net that made it possible for
them to make ends meet.
So, they also talked about the importance of housing and utility assistance, Medicare
charitable foods.
With this idea that we focus very much on SNAP as the largest federal food assistance
support for people, but that it's really the combination of all of these that's making
it work for people, and the sort of demonstrative quote here is, "You've got food, but you can't
cook it if the lights are off."
And I think sometimes we forget about that and we're focused on nutrition programs and
nutrition outcomes.
And then a second theme is that while people thought that the minimum wage was likely to
have a benefit, they were a little bit skeptical of how impactful it would be, given that $15
an hour is not a living wage for many household and household sizes in Minneapolis, and people
were specifically concerned that the cost of living could go up as a result of the minimum
wage.
So, in our analysis, we're going to have to think about the effects of other types of
policies.
Many policies were passed during COVID that could affect our outcomes, and I'm using this
gaps and opportunities slide to really think about how we can, in the next phase of research,
think about not just how single policies affects health outcomes, but really do more sophisticated
studies that look at how these layers of policies form policy context that can either enhance
or inhibit health.
And so, to think about how things at the national level like extra unemployment benefits or
SNAP expansion or the stimulus checks worked synergistically with school food distribution
and charitable food actions during COVID.
I mean, so again, I think that looking at the combination of these policies and how
they can work together is the next area of exploration that I'm interested in.
So, just to sum up minimum wage increases have the potential to have a positive effect
on health outcomes through many different pathways and evaluation of our Minneapolis
minimum wage ordinance is ongoing.
I was surprised to learn how much our study participants were...how common the experience
of food insecurity was.
So, this is a population that is really at a high risk.
When we're thinking about minimum wage and we're thinking about changes in income, we
have to think about the whole spectrum of income-based benefits that that could possibly
affect.
And then finally, as we see minimum wage increase across states and local areas, it really presents
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.
DR. AMY YAROCH: Good morning, good afternoon, everyone.
I am Amy Yaroch, project director of the NTAE Center for the Gus Schumacher Nutrition Incentive
Program, otherwise known as GusNIP and executive director of the Gretchen Swanson Center for
Nutrition in Omaha, Nebraska.
The GusNIP NTAE Center is led by Gretchen Swanson Center for Nutrition through a 4-
year cooperative agreement with USDA NIFA.
The GusNIP NTAE came about as a direct result of the 2018 Farm Bill legislation.
Essentially, the GusNIP NTAE serves as a coordinating center to help both existing and prospective
GusNIP grantees navigate reporting and evaluation and obtain technical assistance.
I want to quickly show you the breadth of partners involved in this endeavor, so you could get
a sense of the incredible expertise across both the reporting and evaluation and technical
assistance and innovation teams.
The Nutrition Incentive Hub was created by the GusNIP NTAE Center to support nutrition
incentive and produce prescription grantees and applicants, and it is a coalition of practitioners,
grocery and farmers' market experts, researchers, evaluators and others from across the country.
At the top, you could see a USDA NIFA, our funder.
We at the Gretchen Swanson Center Service, the GusNIP NTAE Center as well as the lead for
reporting and evaluation.
The boxes on the left signify the many amazing researchers throughout the U.S. we've leveraged
who have in-depth public health nutrition experience to help us on reporting and evaluation.
Technical assistance and innovation is led by Fair Food Network, and they've assembled
a strong team of partners with deep expertise in farmers' market and grocery retail to help
on technical assistance.
I want to next give you a quick sense of the scale and reach of GusNIP to show you just
how much this field is growing.
In just two years of awards so far, GusNIP is reaching coast to coast with a significant
investment of 82.4 million in 2019 and 2020, and new awards are on the way for 2021.
Whereas we saw in the previous slide the locations of the primary awardee for GusNIP funding
in 2019 and 2020 only, this slide shows the total reach of USDA's Food and Insecurity Nutrition
Incentive, or FINI Program, the predecessors of GusNIP and GusNIP funding from 2015 to the present.
It is really exciting to see that this funding and program implementation is reaching across
nearly the entire U.S.
Next, I will describe the GusNIP program types, reporting and evaluation and results from
year one.
There are two main types of GusNIP programs, Nutrition Incentive or SNAP incentive programs
increase the value of SNAP EBT at the point of sale by providing incentives to use at
participating sites, such as grocery stores, farmers' markets and other venues, to purchase
more fruits and vegetables.
For instance, if a participant spends $10 of SNAP on fruits or vegetables, they get
$20 of produce at participating sites.
The other type of program are produce prescription, which are not specific to SNAP participants.
Rather, patients who are low income and experiencing food insecurity and quite often a chronic
condition are prescribed fruits and vegetables by a health care professional, which then
could be redeemed at participating sites.
One of the main reasons we're conducting reporting and evaluation is to better understand and
elevate the impact of these programs.
And it is one thing to see this impact through the individual programs themselves, which
is great.
But when you have the ability to aggregate the data across these programs, working throughout
the U.S. and to me, that's really amazing to see.
With aggregate data, we have the power to see changes in some concrete outcomes.
This can translate into increased fruit and vegetable purchasing and ultimately, fruit
and vegetable intake, along with decreased food insecurity and for produce prescription,
improved health outcomes and decreased health care use and costs.
And to me, that's where the rubber meets the road.
Since we can underscore the need for promotion and implementation of these programs, along
with making the case for continued funding.
This is one of the things that as a researcher and evaluator, I'm truly excited about.
We targeted the data we collected in year one to account for the pandemic.
Despite the challenges of COVID, we were successful in collecting program data from over 700 participating
sites, meaning grocery stores, farmers' markets and clinics offering incentive programs.
You can see the breakdown of what types of sites reported data.
For brick and mortar outlets, the majority of sites were large supermarkets and independent
grocery stores.
For produce prescription, they were mainly small food stores and for Farm-Direct, the
sites were mainly farmer's markets and there were 33 clinics.
This slide displays some of the promising data we saw in year one in the number of sites
again stores, markets, clinics offering incentives throughout the year.
Despite being in the middle of a pandemic, these GusNIP grantees managed to dramatically
increase the number of sites offering these programs, which means they brought many more
incentive dollars to many more families in many more places.
Some of the ebbs and flows you see are based on seasonality and COVID shutdowns.
Again, this is pretty amazing given how much capacity it takes to launch a new site in
non-COVID times.
This slide displays the total incentive program sales among 2019 GusNIP-funded projects in
the local economic impact generated from those sales.
Local economic impact includes both direct effects, sales at participating sites and
indirect effects.
How sites spend the extra revenue, such as on hiring, marketing and other related things.
As the figure shows, the total incentive program sales that is, the dollar amount of incentives
redeemed among the 2019 nutrition incentive in produce prescription projects was approximately
$4 million, which generates an impact estimate of almost $8 million.
This is a win across the board and as such is why incentive programs typically generate
bipartisan support.
If you are interested in finding out more about year one results, you can view our year
one impact findings at nutritionincentivehub.org.
We recently updated our website and launched the GusNIP grantee portal.
Our website, which has the same domain name nutritionincentivehub.org has enhanced navigation,
interaction and search ability and also is publicly available.
So, if you're interested in this area at all, feel free to tool around on the website.
A few interesting things to point out are the GusNIP grantee map and project information,
which allows you to see distinct projects state by state, filter results in various
ways and even export to excel, and we have more than 100 resources that are currently
available on various topics and more to come, including a searchable resource library, which
will be available this fall and allow users to easily search and filter results for hundreds
of resources.
And then communities of practice, this is found under our Join Our Community and is
a great way to connect with other practitioners and experts in the area.
For technical assistance, you can easily request or connect with our team members through our
Request Help Connect Form, which is read and responded to by a real person, and another
feature that's coming this fall are discussion groups as an additional way to connect peer
to peer.
In addition, there's a separate integrated portal with a seamless, secure login where
GusNIP grantees, sites and other specific partners have access to content and information
tailored to their role.
There is robust and secure data reporting functionality and dashboards for grantees
and sites can visualize their project progress.
I appreciate your time and attention and feel free to reach out if you have any questions
and enjoy the rest of the workshop.
Thanks.
DR. LISA HARNACK: It's a pleasure to be here today to talk to you about what we know about restrictions
and incentives in the SNAP program.
A brief reminder of what the SNAP program is.
It's a federal program that provides funds to lowincome families for the purchase of
food.
The amount of funds provided monthly are designed to provide supplemental funds for food purchasing,
meaning that for most households, it's expected that they will use some of out of pocket funds
to purchase food.
The funds are provided on an electronic benefit transfer card that's scanned at checkout like
a credit or debit card.
Most foods may be purchased with program benefits.
Exceptions are restaurant foods, dietary supplements and alcohol.
There's been discussion of ways to reshape the program so that it may better support
family nutrition.
Research clearly shows that the program is effective in reducing food insecurity.
But it's less clear that the program has benefit on the nutritional quality of the diets of
program participants.
One idea that's been discussed is prohibiting the purchase of less healthful foods with
program benefits, for example, not allowing sugar sweetened beverages or other sugary
foods to be purchased with program benefits.
There's also the discussion of pairing these types of restrictions with a fruit and vegetable
incentive, such as a 30 percent bonus on the purchase of fruits and vegetables.
Very little is known about the effect of restrictions or restrictions paired with incentives on
the food purchasing and diet quality of SNAP participants.
We carried out two randomized controlled trials to begin to address this research GAP.
The first study we carried out was called the Filling the GAP study, and we had a follow
up study the GAPS for families.
I haven't the time to fully describe these studies, but in both studies we randomize
households that were eligible are near eligible for SNAP, but not participating. And we randomized
them to food benefit programs that varied with respect to what foods can be purchased and whether there was a fruit and vegetable incentive.
The benefit was provided through a study provided debit card with funds loaded monthly.
Those randomized to a restriction group were not allowed to buy sugar sweetened beverages,
sweet baked goods or candies with their program benefit.
Those randomized to receive an incentive for fruit and vegetable purchasing were given
a 30 percent bonus for any fruits and vegetables purchased using the program benefit card.
For the GAPS for families study, the first study, we found that in the restriction group,
there were some improvements in diet quality and food purchasing relative to the control
group, but not as many improvements as seen in the restriction paired with incentive group.
And that restriction paired with incentive group there was lower calorie intake, lower
sugar sweetened beverage intake, lower intake of those restricted foods, higher fruit intake
and higher overall diet quality in comparison to the control group that received money monthly
for purchasing food following the usual SNAP food purchasing rules.
There was also lower purchasing of sugar sweetened beverages and higher fruit purchasing.
So, this first study certainly suggested that restrictions paired with incentives could
improve the diet quality of SNAP participants.
But our second study, which was a more rigorous study, it did not find benefits of restrictions
or restrictions paired with incentives on the diet quality of program participants,
and I should say that in this study, we looked at the diet quality of not just the adults
in the household primarily responsible for food shopping, that's who we evaluated in
the first study.
We also looked at the diet quality of a child, two to 11 years of age in the household and
for neither the adult or child, did we see any improvements in diet quality or the other
dietary intake outcomes we looked at.
We did find lower purchasing of sugar sweetened beverages and sweet baked goods in both the
restriction and restriction paired with incentive group in comparison to the control group.
In both studies, we also asked those participating in the study what they thought about the restrictions,
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
rules, purchasing rules and what we found in the first study when we asked, what did you think of the restrictions?
We found that 58 percent endorsed the restrictions, 37 percent gave a response to this question that
indicated they were kind of neutral on it and then 5% indicated certain things that
indicated they were not supportive of it, of the restrictions.
In our filling the GAPS for families study, the second study findings were similar.
So, to conclude, I didn't have a chance to describe our study design and go into that,
but there's limitations with the way we designed the study.
Ideally, this evaluation of restrictions and restrictions paired with incentives would
be carried out within the actual SNAP program, where the as trainable validity of findings would
be better.
And so that is a recommendation our research team has, is that that type of evaluation
needs to be carried out to fully evaluate the idea of restrictions and restrictions
paired with incentives.
I want to acknowledge the study team, the community collaborators and funding for these studies.
Thank you for your attention.
DR. MARLENE SHWARTZ: Well, thank you to our three presenters for sharing their really interesting work.
Before we move on to the Q&A, we're going to have a second set of flash talk presentations.
These are highlighting interventions in the health care setting.
So, first, we'll hear from Dr. Hilary Seligman of the University of California, San Francisco.
She will speak on her innovative models of care to reduce food insecurity.
Then we'll hear from Dr. Francesca Gany of Memorial Sloan Kettering Cancer Center, and
she'll talk about her intervention research with cancer patients and medically tailored
meals and other approaches, and then to close the session, Dr. Leonard Egede of the Medical
College of Wisconsin will discuss his intervention work to address type 2 diabetes among AfricanAmericans
experiencing food insecurity.
DR. HILARY SELIGMAN: Hi, my name is Hilary Seligman.
Thank you for inviting me to speak to you today very quickly about new models of care
to reduce food insecurity.
The interventions I'm going to discuss today are based on a screen and intervene conceptual
model, where the theory is that if we can identify food insecure patients in the clinical
setting and refer them to some type of an intervention that can support healthier
dietary intake and improved food security that we may ultimately improve health and
utilization outcomes.
The interventions that people are generally referred to in the clinical setting fall under
three general buckets; onsite programs that are implemented in the health care setting,
community programs which are obviously implemented in the community and then the federal nutrition
programs.
It is the onsite programs and the community based programs that we'll focus on today.
These are generally considered Food Is Medicine interventions.
In general, a Food Is Medicine intervention is considered the integration of a specific
food and nutrition intervention in or in close collaboration with the health care system.
Some examples being medically tailored meals or groceries or produce prescriptions, and
these are generally targeted towards individuals with or at high risk for a serious health
condition, often prioritizing patients who also screen positive for food insecurity.
Let's start with medically tailored meals.
As a Food Is Medicine intervention, a medically tailored meal referral is coming from the
health care setting, and then a community based organization is providing a meal tailored
to the medical needs of the individual patient that is either picked up by the patient or
their proxy or delivered directly to the patient's home.
And there's relatively strong evidence to suggest that these interventions can reduce
hospitalization and readmissions, lower medical costs and improve medication adherence.
Medically tailored meals are suitable for populations with the highest burden of disability
and illness because they do not require patients to shop or cook on their own.
But they come therefore at a relatively high cost, and this creates a challenge for Food Is Medicine interventions.
It is easiest to demonstrate a return on investment and positive health outcomes for these interventions
over a short time window, because these patients tend to be the most chronically ill.
But we don't necessarily want all of our health care investment in Food Is Medicine interventions
to be targeted toward this very high risk population.
There's less opportunity for prevention because disease has already occurred and over longer
time periods, moving upstream and supporting dietary intake earlier in the course of disease
is likely to have the greatest impact on health outcomes and therefore the greatest return
on investment.
Medically tailored groceries differ from meals in that they are raw ingredients that must
be assembled into meals at home.
The advantage is they can be provided at a lower cost to the medically tailored meals.
But of course, they must be provided to a patient population that is able to cook on
their own.
These programs are often sometimes...are often implemented by the same organizations that
provide medically tailored meals as a way to ease patients off of their program, and
they're sometimes provided as independent programs by food banks.
There's little evaluation data on medically tailored groceries, but a recent systematic
review suggested that they can improve food security but have an inconsistent effect on
other outcomes.
Produce prescriptions are also considered Food Is Medicine interventions when they're
tightly linked to health care.
Produce prescriptions are generally a cash value provided on a paper voucher or an electronic
benefits transfer card that can be redeemed at a local vendor for fruits and vegetables.
There are two very large scale programs in the United States; one is the fruit and vegetable
benefit provided through the WIC program, and the other is the GusNIP stream of federal
funding through the USDA that you'll learn more about later in this symposium.
There's lots of heterogeneity in the way these programs look across the country, but there's
moderate evidence at this point in time that they are able to improve dietary intake and
food security.
Modeling studies show that they also have substantial downstream impacts on health outcomes
and health care costs, and emerging data is helping to support this contention as well.
These obviously are suitable for populations with the lowest burden of disability and illness,
and they're often targeted much further upstream towards prevention of the disease. On-site
Food Is Medicine initiatives are generally developed by the health care system to implement
on site.
The lowest catch of these is just educating clinicians and health care staff about the
importance of screening for food insecurity and sometimes this is accompanied by what
we call a passive referral or just handing to patients a resource list if they screen
positive for food insecurity.
Data suggests, however, that these passive referrals have very little impact on food
security, dietary intake and downstream health outcomes.
So, we likely have to do more.
So, health systems have also explored a number of other onsite options.
For example, onsite food distribution through a food pantry permanently located at the hospital
or the clinic that's generally stocked with healthy foods from the food bank, they have
explored mobile food distributions at the hospital or the clinic, where the food bank
mobile food truck arrives once a week or once a month to provide food for eligible patients
and...but the research on these initiatives is still very limited.
And finally, there are a number of initiatives to increase enrollment assistance into federal
nutrition programs like SNAP, the Supplemental Nutrition Assistance Program, formerly known
as the Food Stamps Program.
This type of initiative is moving upstream towards addressing a social determinant of
health, but there have been a number of operational challenges identified, but mostly come back
to the challenges of integrating electronic health records and health systems with the
systems that are used to assess eligibility for federal nutrition programs.
Food Is Medicine interventions overall are challenged by short-term funding that requires
personnel to continue rewriting.
Food Is Medicine interventions are often implemented with the goal of demonstrating a return on
investment, which can be very challenging, particularly in the realm of prevention.
Food is medicine interventions are still often provided for just a very limited amount of
time, perhaps too short an amount of time to demonstrate health outcomes.
Referrals into the community are limited by fragmentation and inadequate funding of the
social safety net and Food Is Medicine interventions are often challenged by changes in priority
populations by funders.
So, funders may prioritize diabetes interventions this year and obesity among young adults next
year as examples.
We also need to support health systems who are interested in addressing food insecurity
and moving upstream from addressing an acute social need or an acute need for food today
towards the social determinant on health of food insecurity, or more specifically, towards
those fundamental drivers or those root causes of food insecurity in the community.
This is the next important wave of this research.
I will leave you with a few good clinical resources.
And with that, thank you for the opportunity to speak today on this topic.
DR. FRANCESCA GANY: Hello.
I'm really happy to be here with you today to speak with you about Food Insecurity Interventions
to Improve Cancer Outcomes.
I'm the chief of the Immigrant Health and Cancer Disparities Center at Memorial Sloan Kettering.
Our mission at the center is to promote health equity for immigrant minority, low SES and
other underserved communities locally, nationally and globally.
And we do this work through research, outreach, patient and community engagement, service
delivery, training, and program and policy development.
And today, I'm going to speak with you about our food insecurity program.
We use the social determinants lens in all of our work and food insecurity is such an
important piece of this.
So, cancer patients often have increased nutritional needs.
However, at the same time, their treatment- related costs such as high co-pays, very high
cost for medications, travel, etc., and income loss contribute to a financial toxicity
and food insecurity goes hand-in-hand with this financial toxicity of treatment of...cancer treatment.
Food insecurity leads to poorer functional, emotional, and social well-being and a higher
risk for depression, and it can lead to care delays, cost-related medication nonadherence,
and then poorer outcomes.
So it is vitally important to screen for and address food insecurity in cancer patients.
in all case...patients, of course, but in cancer patients to potentially improve treatment
adherence and to decrease outcomes disparities for cancer patients.
So given the importance of this, we did several studies in New York looking at food insecurity
in our cancer patients.
So, when we looked at underserved cancer patients in New York safety net clinics, we found that
56 percent were food insecure and disturbingly, SNAP recipients were just as likely to be food
insecure as those not receiving SNAP, which is why it was music to our ears when we heard
recently that the SNAP benefit levels were going up, and we are hoping that this makes
a difference and we will certainly be looking into this.
We also know that food insecurity is a window into other essential needs, such as housing
and other essential needs that are associated with food security status.
When we looked at comprehensive cancer centers, we also found high rates of food insecurity
among the patients between 18 percent to 30 percent were food insecure.
And this came as quite a surprise to the cancer centers, who had no idea that so many of their
patients were food insecure.
Given the large number of food insecure patients, we started to look at food resources.
So, we did a study of community food pantries, for instance, and we found that they do not
address cancer patients' needs.
The hours are wrong considering all of the many appointments people have at the Cancer
Center.
The locations, and also the foods were just not tailored for folks who are undergoing
cancer treatment.
So, we developed a model of a medically tailored Cancer Clinic-based food pantries co-located in the Cancer Clinics.
We now have 14 of these located across New York City and they have proven to be immensely
popular with our patients.
However, we realize that food pantries are not the only answer to food insecurity in
our patients.
In addition to addressing all of the reasons for the financial toxicity of cancer treatment,
when we think about interventions to directly address the food insecurity pantry is certainly
one, but others needed to be developed.
So, we developed a food voucher program that's similar to SNAP in that people get food voucher
cards that they could use at any grocery stores, bodegas, food shops.
They're instructed to use it just for food and non-alcoholic beverages, and they get
a monthly voucher.
And we also developed an intervention that's basically a commercial grocery delivery service,
but that only stocks healthful products.
And these groceries are delivered weekly, and patients choose from a master grocery list.
All of these interventions are accompanied by nutrition, education, and information for
the patients, including tips on how to stretch food dollars.
We took those three interventions, which each seem to have success in their own right, and
we developed a randomized controlled trial to study the impact of each of these interventions
on adult cancer patients at four safety net clinics in New York City.
And was for patients who were starting either chemo, radiation therapy or both and any cancer
diagnosis or stage.
And the outcomes we looked at were treatment completion as our primary outcome, appointment,
attendance, food security status change and quality of life and depression symptoms.
We had great results.
We found that the most effective for improving treatment completion was the food voucher,
plus the pantry arm.
We saw a 94 percent treatment completion in this group versus 82.5 percent for the home grocery delivery
and 77.5 percent for the pantry.
We saw across all arms at 62 or so percent of patients had full appointment, attendance
of chemotherapy and/or radiation therapy appointments.
And this was distributed evenly across the arms.
When we looked at food security status, we saw that there were significant improvements
in mean USDA food security scores in all three arms.
It did differ a little bit across the arms.
The best result was in the pantry arm, followed by the voucher and pantry arm, followed by
the delivery and pantry.
We also looked at PHQ-9 and quality of life and found that across all arms, patients had
fewer depression symptoms at follow up compared to at baseline and for the FACT-G as well,
scores improved across all three arms.
The best improvement for both of these were in the delivery plus pantry arm and the pantry
only arm.
These were the statistically significant improvements.
We looked at the voucher arm food choices and found that on average, 77 percent of the funds
from the vouchers where patients had total choice were spent on healthy food each month.
Interestingly, patients with limited English proficiency spent more on healthy foods and
English speaking patients and patients born outside of the U.S. spent more money on healthy
foods than U.S. born patients.
But this study suggests that providing patients with supplemental funding for food and with
nutrition education, patients are going to make great food choices.
We looked at cost comparisons and found that the pantry only was the least expensive program
to run, followed by the pantry plus voucher followed by the pantry plus delivery.
I would be remiss to not speak about the impact of COVID.
We know how much worse food insecurity has gotten because of COVID.
So we pivoted our food interventions to make them very COVID-responsive.
We started to do curbside pick-up of food and more vouchers and many more home deliveries,
and this made a huge difference for our patients.
But again, the food insecurity was a really important window into other assistance that
patients needed, like assistance with navigation for unemployment, SNAP and other public benefits.
Housing was huge.
So, this is our work on the very patient-centered level.
We're also working across the health systems level, the food justice systems level.
This is, of course, all part of a much bigger ecosystem.
But thank you so much for giving me the opportunity to speak with you about our work on food interventions
and the really big impact it had on treatment completion among our cancer patients and on
quality of life, food security status, and depression symptoms.
And I want to thank our food team, which has worked so tremendously hard on this program,
the entire Immigrant Health and Cancer Disparities Center, and also our very generous funders.
And thank you so much for your time.
DR. LEONAED EGEDE: Good afternoon, everyone, this is Dr. Leonard Egede. I'm a professor of medicine
at the Medical College of Wisconsin.
I'm also the Director of the Center for Advancing Population Science and the director of the
Division Chief of the Division of General Internal Medicine in Wisconsin.
I'm here today to talk about interventions to address type 2 diabetes among African-Americans
experiencing food insecurity.
And one of the things we've tried to do as part of our work is to really focus on the
lived experience of individuals as we develop our interventions.
So, I'm going to share a study that we did that really shaped on how we actually do research
right now in food insecure African-Americans and the strategy you need experience of food
insecure African African-Americans with type 2 diabetes living inner city.
And this was in focus groups that we did. It was a study that was to get insight from the
perspective of food insecure African-Americans living an inner city environment regarding
important diabetes intervention strategies and components.
With the two focus groups with about 16 individuals who are food insecure who also had type 2
diabetes.
We use the grounded theory approach.
Questions were asked as to what challenges and barriers to managing diabetes within the context of
food insecurity and the facilities, or resources that help participants improve diabetes management?
And what I have here is a slide that goes through what the community and the individuals
identified as useful, valuable interventions that will really help them.
So, the first was group-based education, and in that, you wanted to see groups of 10 to
12 people where they could discuss problems and challenges, where they could have discussions
about medication management.
They thought a mixed sex group would be helpful.
And that the health care facility that should be part of that group and it didn't matter
what the risk of the individual was, as long as it was sensitive to the needs.
The second was peer support, where individuals living with the disease could actually serve
as peer mentors and where the mentors would have mastered diabetes and lived with it for a while, where
there were opportunities for peers to share experiences, challenges, and successes for
strategy.
The third was access to community resources on programs where they actually had access
to vouchers to farmers' markets or grocery stores, stock boxes, information about how
to use and cook the food in the boxes, recipe and cookbooks.
And the third…a 1-to-2 month frequency was optimal.
frequency was optimal.
talk openly about stress, having a social worker, a clinical person to provide counseling
on stress.
And a fifth category of interventions with faith-based programs where it was positive
messaging, prayer, and use of scripture verses, motivational messages.
So we have used this as a way to actually develop and test our interventions.
But what we also find as part of the focus group was that we actually realized that stigma
was a big issue.
And so, the current USDA food insecurity measure doesn't really account for some of these issues.
So, I want to share with you a food insecurity risk tool that we've developed that allows
us, to really hone in on the needs of the community.
So the current USDA measurements does not account for contextual factors and the multidimensional
risk for food insecurity that's associated with the underlying issue of poverty.
The poverty drives a lot of what we see.
It does not account for stigma that's associated with food insecurity, and it also does not
assess food and nutrition security defined particularly as supported by an environment
of adequate sanitation, health services and care wanted for a healthy and active life.
Then also, we've also found that measuring food security apart from nutritional security,
creates gaps in understanding and addressing the problems typically associated with food
insecurity, especially for individuals with chronic disease.
So we've created this tool—it has about seven items—and there's a yes or no items, which
a yes been a score of one and no been a score of zero.
The first item is: Would your annual household income be described as this at $25,000?
Two: Did you ever go without food, clothing or housing because she needed the money for medical
care?
Three: In the past 12 months, would you say you were worried or stressed about having
enough money to pay your rent or mortgage?
Four: In the past 12 months, would you say you were worried or stressed about having
enough money to buy nutritious meals?
Five: Was the time in the past 12 months when you needed to see a doctor but could not because
of costs?
Six: Was there a time in the past 12 months when you did not take your medication as prescribed
because of cost?
And seven: Do you consider your neighborhood to be safe from crime?
And then so, we scored this on a scale of zero to seven with a score of two or more being indicative
of food insecurity.
We've tested this in multiple models right now, and what we have here is an analysis
that we did looking at the food insecurity risk tool, as a predictor of food insecurity using
the USDA tool.
And in this case, if you are two or more... if you score two or more overall you had almost
4.5 times the risk of having food insecurity.
If you score three questions positive, it's 13 times increased risk.
If you are four or more, you are almost at a 54 increased risk of food insecurity using the
USDA tool as the benchmark.
We also then looked at this in the diabetes population, the African-American only population,
African-American and diabetes population.
And the results are very consistent in terms of what that means.
So, a score of two or more really helps you identify individuals who are at high risk
for food insecurity, but does not put them at a position where they actually have to
declare specifically, you know, these types of issues they are highly, but also minimizes,
the stigma associated with insecurity.
And so we are now doing this study right now that we're calling lowering the impact of
food insecurity in African-American adults with type 2 diabetes, according to LIFT-DM study.
And this study was funded by NIMHD, it's a five-year NIH R01.
And the background is that there are currently no randomized trials that indicate whether
food supplementation is beneficial to improving glycemic control.
We know that food supplementation is useful, but it does...there's really no study on what
does that do for a food insecure individuals and their diabetes control.
So, in the LIFT-DM maximizes resources through a factorial design to test a series of essential
questions for informing cost-effective, efficacious strategies to improve health for food insecure
African Americans with diabetes.
We have three questions:
Does food supplementation compare with diabetes education, improve that outcomes beyond diabetes
education alone?
Two: What type of food supplementation is most effective?
And three: What combination of food supplementation and diabetes education is most effective in
lowering glycemic control?
So, you need two-by-two factorial design, and the idea is one group gets usual care with
just diabetes education.
Second group gets a food supplementation via vouchers, and the third group gets food supplementation
via stock boxes, and the fourth group gets the combination of vouchers and stock boxes.
And we're going to follow them for 12 months to see if their diabetes control is better
and their quality of life is better.
And this would give us really important information about food supplementation for
people with diabetes, and also for those with chronic disease.
And so, in conclusion, what are the future directions that this field needs to go to?
One is how do we address stigma as attached to food insecurity?
Two is, what kind of tailored interventions do we need to build that builds upon on the lived
experiences of African-Americans in an inner city environment?
The third area is the idea of using a food insecurity risk tool, which allows us to capture
individuals who are food insecure but does not allow them to feel stigmatized as a result.
And then finally, addressing food insecurity as a poverty issue, as opposed to an isolated
problem.
We believe that interventions that focus on structural racism and policies that perpetuate
poverty are needed to really address this issue, and novel interventions that focus
on alleviating poverty as a strategy to alleviating food security are needed.
So overall, we think this is going to get us in the right direction as we begin to do
more work focused on really treating poverty as underlying framework for food insecurity.
Thank you.
DR. MARLENE SHWARTZ: Thanks, everyone, for those wonderful presentations.
We have some questions.
The first one is for Dr. Amy Yaroch, and it's about efforts to evaluate the impact of deafness
incentive programs on health outcomes.
DR. AMY YAROCH: Yeah, that's a great question.
Thanks, Marlene.
So, GusNIP grantees both nutrition incentive and produce prescription programs are assessing
self-reported health status among their participants, but for produce prescription programs,
some of the grantees are clinical in nature and so...or they're partnering with clinical
groups and linking to electronic health records.
And so, they are...actually are assessing clinical markers like A1c, BMI, and other health outcomes.
DR. MARLENE SCHWARTZ: Great, thank you.
So, there are a couple of questions for Dr. Lisa Harnack about the work that you presented.
And one of them is about whether the use of restrictions might lead to demoralization
among those who are in need of assistance.
And then sort of relatedly, what were the perspectives of SNAP participants in the paired
intervention?
DR. LISA HARNACK: Right.
So really good questions.
You know, when we asked people who had been receiving benefits with the restrictions in
place, you sort of saw what I presented in that most either had a positive reaction or
a neutral feeling about it.
With the positive reactions it was often people saying, you know, "It's good for me, it's,
I want to eat healthier and this is, you know, nudging me or helping me with
that."
So, it didn't seem to be demoralizing.
It seemed to, you know, although for the small percent who are opposed to it, they could
feel demoralizing.
In particular, we heard people say, "Well, this means I can't get, you know, a cake for
my granddaughter's birthday party" or something like that.
Like, this sort of, no sweets...would...might be too extreme for some
people.
And then when we looked at people who were paired with the restrictions and the incentives
and the restrictions only they had similar levels of support for restrictions.
It didn't look like the incentives, paired with that changed that outlook.
When we asked specifically about the incentives uniformly, everybody loves the incentives.
You know, this is a really great thing from the participant perspective to be getting
an incentive for buying fruits and vegetables.
DR. MARLENE SCHWARTZ: Thank you.
So, there's another question about whether... and I think this is correct.
There wasn't an incentive only group in the study. Is that...is that right?
And the question is why?
DR. LISA HARNACK: In the first study there was and for the ease of convenience of presentation,
I didn't show the results.
But in that first study, there was an incentive only group.
And the effect on diet was increasing fruit intake and no other effects on diet quality.
In the second study, the funding organizations said, "You know, we kind of already know what
incentives alone do between the healthy incentive pilot study and your previous study.
Please focus on restrictions alone and restrictions paired with incentives."
So that's what we did in the second study.
DR. MARLENE SCHWARTZ: Great. Thank you.
So, a couple of questions for Hilary Seligman.
One: Can you talk more about insurance coverage for Food Is Medicine interventions?
And can you get that under Medicaid or Medicare?
And then also, can you talk about any Food is Medicine interventions provided by RDs
in clinical settings?
DR. HILLARY SELIGMAN: There are great questions, let me start with the insurance coverage.
I would say that insurance coverage for food is medicine interventions is very patchwork
and spotty right now.
There are states that have applied for Medicaid waivers to cover Food is Medicine interventions.
And so, there is some opportunity for a coverage depending on your area.
And there is some consideration of making these benefits more federally available but
that has not happened yet.
There are also programs within private insurance insurance companies to cover programs such
as medically tailored meals.
As far as RDs go, I would say RD involvement in this space has been extremely important
in their participation and involvement has come in two ways.
The first is most of these food as medicine interventions have a nutrition education component
to them.
I was particularly focusing on the provision of food, but I think it's really important
we call out the provision of education as well, and RDs are usually driving that component.
And the second way is by being the clinical champion.
All of these Food Is Medicine interventions can only get off the ground with a really
involved clinical champion, and RDs are often playing that role as well.
DR. MARLENE SCHWARTZ: Great, thank you.
So, a question for Dr. Caitlin Caspi, you talked about toward the end of your presentation
this idea of layering different policies to look at impact.
What types of local policies do you think we should be thinking about that would actually
pair well with a minimum wage policy and amplify in particular, the health benefits?
DR. CAITLIN CASPI: Yeah, thanks for that question.
So, we're thinking about this a lot in our wage study because Minneapolis, as a city
that...who had that with a city council that's likely to pass a minimum wage ordinance, it's
also going to be the type of city that's considering a number of other policies that could, again,
it could enhance the effects of the policy.
So, for example, they also passed a paid sick leave bill ordinance around the same time.
There's been a lot of discussion by City Council around housing and single family zoning, affordable
housing in the city, as well as a lot of discussion and reckoning around policing policies.
And so, I think that when we're thinking about sort of local policies that can address sort
of economic stability, it can also include affordable housing and the ways in which we
live in and increase how safe we feel in our communities.
And so I want to say that we're thinking about this because in contrast, the same types of
cities that are not considering minimum wage policies are also going to be policies that
then are not considering policies like potentially housing policies or paid sick leave.
And it can potentially increase the geographic disparities
when you have this sort of layering effect of local policies.
And what that speaks to is the importance of federal policies and those that can sort
of cover a large swath of the population in order to not increase the disparities.
DR. MARLENE SCHWARTZ: Hey, thank you.
So, a couple of questions for Dr. Francesca Gany, one of them is: Did you measure malnutrition
improvements in the cancer patients who you're working with that, who were participating
in the different intervention arms?
And then the second question is a follow up to your observation about that the food that
was in the food pantries and why you decided to create this targeted...specialized food
pantry.
Do you think that a food pantry that was in general trying to really focus on providing
healthy foods that meet the dietary guidelines would be different than what the pantry that
you guys created?
Or do you think that that would sort of meet the needs of most cancer patients?
DR. FRANCESCA GANY: Yeah, great.
So, in terms of the first question, we are studying nutrition indicators and it seems
like across all three arms we saw tremendous improvement, but we're still analyzing that
data.
But it looks like all three forms were important in terms of looking at indicators of poor
nutrition, etc.
In terms of just what a great, balanced diet with whole foods and fruits and vegetables,
and which would be healthy for everyone, that would certainly be fabulous for the cancer
patients.
The only difference is we have a little bit more leeway in terms of a couple of things.
One is, when people have cancer related symptoms and need a little bit more choice and a little
bit more tweaking and tailoring, we're able to sort of swoop on in and help that way.
I mean, that's really the biggest difference.
And the other thing is, if folks have some mechanical issues secondary, eating secondary
to their cancers, then we're able to help in that regard too and really tailor it that
way.
So generally, healthy diet would be great for most of our patients, but we do need to
tweak it in some additional ways.
DR. MARLENE SCHWARTZ: That's really, really helpful and really interesting to sort of appreciate the
nuance there.
Dr. Egede, there is a question for you about, if you have suggested survey tools that can
be used to measure and better understand the stigma around food insecurity?
DR. LEONAED EGEDE: Yes. So, can you hear me?
DR. MARLENE SCHWARTZ: Yeah.
DR. LEONAED EGEDE: So, I think this is something we've actually been working on for a while
now.
So there are a couple of tools that are really focused on food pantry stigma.
So going to a food pantry but there's nothing out there that really measures stigma across
the board.
So we are actually developing a tool right now and painlessly destination one of our
studies.
We should be able to have something that's valid and reliable, probably by the end of
the year.
But there is nothing right that can actually measures that level of stigma.
DR. MARLENE SCHWARTZ: Great, and then a second question just came in for you as well.
You talked about food supplementation intervention along with nutrition education for diabetes,
and the question is, is this whole food through pantries or a targeted prepared meals delivered
during the study time?
And also, did you take cultural component into consideration so that the culture of
the people you were working with?
DR. LEONAED EGEDE: Yes, I think this is one of the challenges.
I'm sure there was this work your how challenging this is.
So we partnered with Hunger Task Force.
And so we provide vouchers, we actually provide and you can actually go to the mobile van
and actually pick up items.
And we actually suggest items you can pick up.
The stock boxes actually developed in such a way that we try to get things that are relatively
culturally appropriate, but that's very limited ability to modify the stock boxes directly.
So in terms of, you know, the issue about the vouchers and stock boxes there are relatively
kind in terms of stock boxes.
The vouchers, you have a lot of options in terms of what you can pick.
The combination is a combination of both, and that actually came from focus groups where
people asked "Can we have both?"
In terms of the culture of tailoring the items, what we are finding for focus groups is not
just the food, is also have to prepare the meals.
So, you know in addition to items that got you want people asking questions about what
should you know, I need to be familiar with this food, I need some idea of how to actually
prepare some of those meals.
So, we're working on how to modify some of the structures going forward.
But the key thing is that when you create a truly culturally two boxers, there are going
to be very expensive because you're actually going to have to look into not just a culture
where individual preferences.
DR. MARLENE SCHWARTZ: Right, right. Thank you.
So the next question wasn't directed towards any individual person, but it was about whether
any of you know of data regarding interventions that are tailored to the elderly or seniors
65 and over?
DR. LEONAED EGEDE: I think there are pilot studies done mostly pilot studies that we've come across.
I'm not aware and I could be wrong, but I'm not aware of any large randomized trials where
they've actually focused on the elderly, where they've actually done special studies, especially
to the elderly, but others may have other ideas.
I'll just write two potential avenues to look into.
One is any of the programs that are implemented through Medicare are going to obviously be
that age group.
But also there was a really lovely study done on SNAP enrollment, outreach and assistance
and referrals to community benefits among dual eligibles at an organization called Benefits
Data Trust.
And they were able to show really, positive impacts on food insecurity rates with the
work that they did.
So I would also look up the work done by Benefits Data Trust.
DR. MARLENE SCHWARTZ: Right, thank you.
So two people actually wrote in very similar questions, and this is a big question, I think
directed to everyone, which is how sustainability, environmental food system sustainability fits
in with the interventions you presented or with your plans for future programs and research.
So I'll let whoever would like to take a crack at that one first.
Go ahead.
DR. FRANCESCA GANY: I can jump in with two quick comments, the first is that diets that are high in fruit
and vegetables are less burdensome to the environment than diet high in meats.
And so almost all of the interventions we've discussed today really encourage people to
adopt a plant forward diet, which is positive for the environment.
The second thing is that a lot of these interventions also encourage people to buy foods from smaller
grocery stores and farmer's markets, which enhance local food production and purchasing.
And to the extent that that also supports environmental sustainability, I think these
programs are really heavily in alignment with climate change efforts.
And I'll just add on him to say USDA
step was made a permanent part of the Farm Bill.
And so if we can show positive outcomes like increased fruit and vegetable consumption
and some of these health outcomes, then we can really help to continue to make the case
for these programs and sustainability of them.
And again, fruits and vegetables all about incentives. So...
DR. MARLENE SCHWARTZ: Alright, thank you.
OK, well, we are at the end of our time. It's been great.
I want to thank everyone audience for your questions and our panelists for sharing their
innovative intervention work.
Next, we are going to move into our networking break so you can engage with your fellow attendees
on the topics we just discussed.
And there you'll find a moderated chat discussion to share your takeaways and highlights from
these innovative interventions.
Please participate in the networking lounge until 4:55 p.m., and at that time, we will
begin our final presentation of the day, which is gaps and opportunities to address food
insecurity and promote racial equity in the context of structural and social determinants
of health.
Thank you, everyone.
Thank you.
DR. ANGELA ODOMS-YOUNG: Welcome back, everyone.
Hopefully, you enjoyed the discussion during the networking session.
I have the pleasure of introducing our final speaker is going to talk about gaps and opportunities
to address food insecurity and promotion of racial equity in the context of structural
and social determinants.
Our final speaker is Dr. Mariana Chilton, who is a faculty member and researcher at Drexel
University, and she will provide some insights into bigger-picture topics related to food
insecurity and what are some of those drivers of inequities in food insecurity?
So she's going to explore what are the structural drivers and social determinants of health
that intersect with food insecurity?
What are the gaps and opportunities to address food insecurity and promote racial equity?
And we are so excited...
we are so excited to hear the exciting presentation from Dr. Chilton.
So, I'm going to turn it over to you, Dr. Chilton.
DR. MARIANA CHILTON: Hello, everyone, thank you so much for tuning into my talk on the gaps
and opportunities to address food insecurity and the promotion of racial equity.
My name is Mariana.
I'm a professor at Drexel University, School of Public Health, and I'm making this recording
on the lands of the Lenni-Lenape in the area around Philadelphia, Pennsylvania.
And I acknowledge their elders past, present, and future.
And I recognize that the land should be returned to them with restitution and reparations.
Also, almost all of the photos in this presentation are from Witnesses to Hunger.
So, this wasn't the full title of my talk.
The rest of the title is about 'Promotion of Racial Equity in the Context of Structural
and Social Determinants of Health.'
So, for you, this is an invitation to rethink and to remember what we're doing when we're
doing food insecurity research, and I encourage you to take good care because I will be talking
about traumatic events.
So first of all, I want us to take context more seriously than we currently do in the
world of food insecurity research.
I'll talk about racial and ethnic and gender disparities.
I'll talk about the importance of taking intersectional lens and also integrating critical race theory.
I'll talk about exposure to trauma and violence and how a life course approach helps us to
integrate attention to trauma and violence.
Then I'll get to the gaps and finally to the opportunities.
So, before I begin, I want to acknowledge the relationships that I've had with my research
participants over the last 25 years.
I used to work with the Southern Cheyenne and Arapahos and the Kiowa, Comanche, Caddo
in Delaware in western Oklahoma in the 1990s.
And for the past 21 years, I've worked with a lot of really beautiful families, primarily
black and Latina women, and I want to honor my relationships and my kinship with research
participants.
And I encourage you to take a moment at this point to also acknowledge and send some gratitude
to the research participants in your own studies and to remember their humanity.
First of all, I want to talk about the spectrum, food insecurity across the continuum.
So yes, food insecurity is not hunger.
I know many of us are frustrated with the conflation of these two terms.
But that does not mean that we can portray food insecurity as a mere technological expediency
without considering the context, we must remember that food insecurity is a part of a continuum.
So most of us, of course, are dealing with what sometimes is referred to as hidden hunger
or chronic food insecurity, but deeper forms of food insecurity are forms of starvation.
So, I want to start there and acknowledge the starvation of Indigenous people in the United States.
Starving Indigenous people was a part of... it was an act of war and genocide in this
country, and we have to remember that when we're talking about food insecurity among
American Indian populations.
So this is a famous photograph of people standing on top of millions of buffalo skulls.
And here's an example, in 1873, the American government killed 1.5 million buffalo in that
one year alone, and that was to starve Indigenous communities across the United States.
Who ordered this kind of murder?
That would be Buffalo Bill Cody, Union Major General Philip Sheridan, and the 18th President
Ulysses S. Grant.
This was systematic war and genocide, and we must remember that.
It wasn't just there were so many different ways that we starved American Indians into
submission, killing sheep as well that was happening up through the 1930s among the Navajo.
And we have to remember that whenever we're talking about hunger, especially among American
Indian communities.
This is why we must understand that hunger and food insecurity are a question of power
and domination.
Scholars have been talking about this for over 100 years of just identify a few Peter
Kropotkin talked about the importance of equity, he says, "In solving the question of bread,
we must accept the principle of equality which will force itself upon us to the exclusion
of every other solution."
I make the same argument today.
Josue de Castro talked about hunger is man-made.
He was the head of the Food and Agricultural Organization in the 1950s.
Of course, Martin Luther King talked about food insecurity quite often, he said, "It's
a crime for people to live in this rich nation and receive starvation wages."
Amartya Sen, Nobel laureate, talked about hunger is a form of entitlement failure and
that our focus on food has caused deep conceptual confusion.
And finally, most more recently, Mike Davis talked about how the British created massive
famines through harnessing British rule and neoliberalism, taking advantage of the El
Nino weather patterns.
He said, that, "Millions died not outside the modern world system but in the very process
of being forcibly incorporated into its economic and political structures.
They died in the golden age of Liberal Capitalism.
Indeed, they were murdered."
When the climate catastrophe is upon us, I want to make sure that we're also paying attention
to how the climate crisis affects food insecurity and will affect food insecurity today.
This is an example of a photograph from Hurricane Ida.
So are we paying enough attention?
Are we finding out ways to build resilience, collective resilience so that we can survive
the future when things will get even far worse?
In other words, perhaps we ought to think about our food as persons in the example from
the Ojibwe, who are now fighting to protect their waters and their lands and their rights
by suggesting that Manoomin is a person.
Manoomin has rights using the rights of nature.
So back to what's going on presently in terms of food insecurity, who has the highest rates
of food insecurity and why?
This also helps us understand the context.
Of course, Indigenous nations and communities have the highest rates of hunger on U.S. soil,
and among the Navajo, the rates were at 80% when they were last measured.
People with disabilities- extremely high rates around 40 percent nationally.
Households that are headed by women or friends have rates between 30 and 35 percent of food insecurity.
Of course, Black and African-American families, Latina families have rates that are two to
three times that of white.
People who are immigrants have extremely high rates.
People who are lesbian, gay, bi, transgender, queer, intersex or asexual, and beyond have
much higher rates than the general population, as well as people returning from prison.
What ties all of these communities together?
What is the common theme?
That would be discrimination.
This is what we must pay attention to.
So, we think about just racial and ethnic and gender disparities have continued to happen
since we've been measuring food insecurity back since 1995.
Looking at rates of food insecurity by race and ethnicity, we see that the United States
has made very little progress in reducing ethnic and racial disparities over time as
well in terms of gender.
Look at the rates of female, of the rates of women-headed households.
We have done nothing to reduce these disparities over time.
This is despite a robust nutrition assistance series of programs.
So we need different lenses of understanding to try to create better solutions, more targeted
solutions to reduce racial and gender disparities.
The first lens that we need to use is intersectionality.
Intersectionality was developed by Kimbery Crenshaw.
It's about recognizing how our current and historical legacies of simultaneous racism
and sexism, of course, by extension, homophobia, transphobia, and xenophobia create the oppressive
conditions that cause poor health, lack of rights and opportunities, and ongoing discrimination
against Black women, girls and fems.
This, of course, upends our current ways of thinking in our usual ways of trying to solve
problems.
But we must incorporate this recognition that oppression is intersectional.
Another way we can use, we can understand what's going on with food insecurity is focusing
in on using racial, critical race theory, which understands that racial and ethnic disparities
that we see today have their roots in racism in all our systems.
This makes, this means that we need to pay attention to history and making sure that
we are tracking inequity across the generations.
So understanding these ways of, these two lenses of understanding help us to see that
the genocide of Indigenous people, land theft, and enslavement of African peoples are at
the root of the current social determinants of health.
Genocide and enslavement are forms of trauma where they create traumatic conditions.
Trauma is an emotional, cognitive, physical, spiritual, and relational response to a terrible
event or series of events such as accident, rape, or natural disaster.
Again, enslavement and colonization create traumatic conditions, and this can include
experiences of torture, starvation, imprisonment, etc.
At an individual level, we understand trauma to include issues, such as rape or intimate
partner violence, physical abuse, sexual abuse, and bullying, community trauma and beyond,
including traumatic grief, that's unresolved grief from death or witnessing terrible experiences.
But there's also forms of trauma that spread across the generations.
This can be historical or intergenerational trauma.
Historical trauma is the cumulative psychological and emotional wounding across generations
that emanates from massive group trauma, and this can include historical unresolved grief
that can accompany that kind of trauma, and that comes from Dr. Maria Yellow Horse Brave
Heart.
Intergenerational trauma are ways in which trauma is passed on through a family so it
can be experienced in one generation of a family and affect the health and well-being
of their descendants as well.
There is collective trauma, such as a cataclysmic event that shatters the basic fabric of society
or the loss of life and crisis of meaning.
One would argue that experiencing the COVID-19 pandemic over the past 18 months has been
a form of collective trauma.
Finally, a life course approach helps us to also understand how food insecurity and violence
can be transferred across the generations.
If we think about early childhood and the brain growth during early childhood, that
any kind of toxic stress can damage the brain architecture.
So any kind of nutritional deprivation in early in life can have severe lifelong consequences.
As an example, many of you may be familiar with adverse childhood experiences, this can
be abuse or neglect or household instability inclusive of having a parent who was incarcerated
or witnessing abuse in the household.
Families that have three or more ACEs are considered to have ACEs high.
And there's a lot of research that's coming out now on the relationship between ACEs and
household food insecurity as an example of how ACEs and food insecurity are related.
I'll introduce you to a publication I did with Dylan Jackson and several other authors
based on the 2016 National Survey of Children's Health.
Our sample size was over 50,000 and you can see with 3+ ACEs or ACEs high when there were
people, when compared with people with no adverse childhood experience exposure, exposure
to three or more adverse experiences corresponded to an eightfold increase in the relative
risk of moderate to severe food insecurity.
If you look at what also is going on individually, like individual ACEs, you'll see that those
who live with people who had a drug or alcohol problem or had experienced unfair treatment
because of race and ethnicity had a fourfold increase in moderate to severe food insecurity.
Very similarly, those who experienced or who witnessed physical violence in their home
also had major increased risk of moderate to severe food insecurity.
There is plenty of evidence out there.
It tends to be neglected or ignored.
Please take a screenshot and become familiar with the evidence.
So what I want us to do is pay more attention to racism and sexism, violence and injustice,
how these are related to disrupted relationships and isolation, poor school and job performance,
poor physical and mental health, and precarious living conditions, of course, which manifest
in economic insecurity, in which manifest in food insecurity and other insecurities.
And, of course, poor health, which most of us do our research at that level.
However, most of us are skating along the surface, and that's because we tend to take
a biomedical approach and focus primarily on food.
But if we continue to invest our resources and our interventions that... interventions
at this level, we are going to see more and more diminishing returns because we are neglecting
the other issues that are going on underneath.
So I'm recommending that we focus more on racism and sexism and violence and how these
are related to the kinds of conditions that create economic insecurity.
So, I am inviting us to allow ourselves to recognize and name the violence associated
with food insecurity.
Recognizing that low wages and their relationship to food insecurity is about being devalued,
that's a type of violence against working people, how we have discriminatory policies,
paying more attention to adverse childhood experiences, and of course, remembering that
food insecurity is rooted in our relationships.
That is, it is about power and control.
People in power, primarily white and western European, who have a history of oppressing
minorities and marginalizing people by harnessing techniques of domination.
Some of these I've already talked about.
So the gaps are our limitations and our ideology.
Again, we tend to stay at the surface.
Our scientific methods are also quite limited, we tend to utilize a very western European
framework, which looks at very proximate outcomes.
We have a lack of diversity of people doing the research, especially those who have lived
experience with economic precarity setting and who are not able to set the research agenda
and do the research.
I'd also have to say that the NIH itself is quite limited because of our demand for clinical
and nutritional outcomes, the short windows of research funding and our desire for outcomes.
And finally, I'd say a lack of desire to change our status quo.
So, we have lots of opportunities to broaden our framework frameworks and ideologies.
We need to take more intersectional approaches and integrate critical race theory, focusing
on equity in emancipation, human rights and rights of nature, incorporating more clear
theory and feminist theory, being trauma informed in our approach in our look at outcomes.
And I'd have to say we need to incorporate more Indigenous ethnic ethics of reciprocity
and mutuality.
This, again, can be incorporated into our methodologies, doing more participatory and
inclusive type of research studies, incorporating more anthropology and ethnography and ecology,
focusing less on description more on intervention and action, becoming more joyful in our approaches
and our methodologies.
And finally focusing in on financial, social, and spiritual outcomes, as well as mental
and physical well-being of humans.
So these are achievable and possible.
As a quick example, I give you one of our own studies from the Building Wealth and Health
Network, which is a trauma-informed approach to helping primarily women who are on temporary
assistance for needy families to come together in groups, to come together in a circle to
address issues of trauma, racism, and discrimination, and also to build up their bank accounts and
their sense of financial security.
We had no food involved, and we were able to reduce the odds of household food insecurity
by 64%, and we were especially successful among those who had experienced violence.
So this is very possible.
If you want to learn more about the context behind food insecurity and hunger, you can
read our article the Catherine Alaimo, Sonya Jones and I, wrote last year it came out and
present knowledge and nutrition, chapter 17.
More specific opportunities are we must prioritize research, prioritize funding researchers from
minorities and marginalized groups and prioritize research that promotes action in policy change.
That means taking an intersectional lens on work and wages and labor laws, making sure
that we're focusing in more on interventions that help to improve racial and gender equity,
focusing in on promoting Indigenous sovereignty and free prior and informed consent and ensuring
that we're building resilience in our ecosystems and our human interactions.
There's lots of excitement now with the Biden administration, with changes in the SNAP calculation
as well as pandemic EBT.
Let's take an intersectional lens to ensure that we're focusing in, especially on Black
women and Indigenous women, and improvements for them.
We also need to make sure that we're developing models based on more transformative policies
that address equity, such as reparations for enslavement and reparations, and rematriation
for Indigenous sovereignty, focusing on universal basic income or minimum wage increases.
And what could happen if we could get police out of schools and making sure that we're
preparing for the climate catastrophe?
Finally, we'd like to make a plug for trauma-informed solutions that are healing centered to do
more violence prevention.
If we can reduce violence, I know I can guarantee you will reduce economic insecurity and food
insecurity.
And finally, thinking and acting for seven generations ahead. Thank you so much for listening in to this talk.
Please feel free to stay in touch.
DR. ANGELA ODOMS-YOUNG: Thank you so much, Dr. Chilton, for that very thoughtful and reflective talk.
I will start out actually with the first question as we see people to some, I think people will
start putting questions in the chat.
If you haven't already, I know that this is a very reflective talk in the sense that it
explores some issues that we don't always think about in the context of food insecurity.
And you talked a little bit about using critical race theory.
You talked about other types of methodological approaches.
And one limitation, even as someone who studies race and I have an interest of race is training.
We have a lot of people who are trained as nutritionists.
I'm trained as a nutritionist.
I am at the nutrition department.
So one question that I would have, particularly for researchers, is what recommendations would
you have when it comes to training of how we should be trained in the next generation
of researchers to meet some of the opportunities that you mentioned?
DR. MARIANA CHILTON: Thank you so much for the question, and I too have suffered from the
lack of training and I've had to learn by doing and often learn by the seat of my pants.
I'd have to say that I've also learned from my direct experiences in working with the
Southern Trans Arapaho, as well as Black and Latinx women in Philadelphia and all over
the East Coast, who have forced me to pay closer attention to issues of racism and sexism
and discrimination.
You know, I think it's very clear that those who have who get training in nutrition know
a lot about micronutrients and also about the food system, but there is a kind of blindness
that all of us have, or I don't want to say blindness.
I mean, sort of a lack of awareness that it's the structure of higher education, which is
also dominated by a white supremacist type of culture.
So it's not really just in nutrition, it's also in public health that people are lacking
this training.
It's also in sociology and beyond.
So, I think if more of us food insecurity researchers could pay greater attention to
issues of racism and discrimination and incorporate more history, I think that we would be able
to draw in people from other disciplines to start to engage on food insecurity work.
And I think that we all have to take a broader approach and be unafraid to talk about critical
race theory.
We need to bring, you know, hopefully, the teachers K through 12 are starting to integrate
more attention to racism and discrimination and to the harms of colonization.
We just all have to do better and we have to make room in our courses.
We can't say, "Oh, today we're going to talk about food.
And tomorrow we'll talk about racism and discrimination."
Everything should be seen through the lens of racism, sexism, capitalism to allow us
to have a broader understanding of what's going on.
We have to take these things that are called blinders, which I don't like the word, but
we have to take them off and all of us have to do it.
We can all do better, myself included.
DR. ANGELA ODOMS-YOUNG: Thank you, we have a question in the chat.
Given the importance of intersectionality, what do you believe is the ideal role of food
banks now and in the future in addressing food insecurity?
DR. MARIANA CHILTON: Thanks for the question.
I don't think there is an ideal role for food banks because emergency food and food banks
are not accountable really to anyone and not even accountable to their local communities.
They tend to be accountable to their funders and tend to focus on the distribution of food
without paying attention to issues of racial and gender equity, and to the trauma that's
underneath so much of hunger, so much hunger today.
I think that existing food banks could do a lot more to really engage with the communities
that they serve to do more, to be less of a one-way experience, to create opportunities
for mutuality and solidarity.
So perhaps, turning food banks into a cooperative, like a food cooperative where people are proud
to go to the food bank because they know that they're contributing to their own community
and that they're contributing to community resilience.
Anything that food banks can do that promote community resilience, promote human rights,
the right to food, and promote food as a right, not as a charity we'll be in good stead.
DR. ANGELA ODOMS-YOUNG: How would you recommend funding for grants to be more equitable across
diverse investigators so more work can be done in this area?
Do you have any recommendations about funding?
Funding is always an issue that comes up.
How what recommendations do you have for funding to be more equitable?
DR. MARIANA CHILTON: Well, I think that those who are who control the purse strings of our
funding mechanism need to look in the mirror very closely about whether they're really
adopting an equity type of lens.
It's painful to do that because we tend to be attach.
My guess is that we get attached to those who have long CVs and excellent training,
supposedly excellent training, and who know how to write those grants.
I think that if NIH and USDA could really take into account issues of vulnerability
and personal and lived experience and make a commitment that for the next five to ten
years, that they will prioritize researchers and investigators from minoritized communities
and create opportunities for them to get training and to propose new solutions to propose new
methodologies.
And many of them are not new.
Some of them are older or, you know, thousands of years old.
These types of scientific methodologies, Indigenous methodologies, and also I know that philanthropy
is really is rife with issues of racism and sexism, and classism.
And there are funders that are looking to decolonize the way that they fund do their
funding.
And when I can circle back around, I can do a quick Google search on some people that
are working on helping to find ways to ensure that funding gets directly into Indigenous
communities and in partnership with Indigenous communities.
We have to, I think about Ruthie Wilson Gilmore, who's an abolitionist and a geographer, has
talked about, if we're going to, she talk about abolition.
But I take an abolitionist approach to food insecurity.
We have to change, now, we have to just change one thing, which is everything.
The funders are part of the problem, the way that we teach about food insecurity, the way
that we teach our methodologies are part of the problem.
The way that we understand the history or lack thereof of food insecurity is a part
of the problem.
So all of us have a part to play in centering an equity type of a lens.
DR. ANGELA ODOMS-YOUNG: The next question from our attendees says, "I absolutely loved your
presentation, Dr Chilton.
I run a food insecurity program in North Philadelphia out of the Center for Urban Bioethics.
Racism continues to have a huge impact on healthy food access, and the two biggest barriers
we see to healthy food access are cost and access.
What do you see as the role of academic medical centers and academic centers that are housed
in neighborhoods that suffer from food insecurity?"
DR. MARIANA CHILTON: That's a little bit like the question of what can what is the ideal
position for food banks, right?
When I think about university systems and health care system, we are a part of the problem.
Our institutions tend to suck resilience up neighborhoods in which we are housed.
Drexel is a case in point in the City of Philadelphia.
So, it's not just about working with people from the neighborhoods, but it's also about
working with your home institution to ensure that they're investing in housing in the local
community, that they're investing in building community resilience, that they're hiring
local people for all of their staff and university jobs and paying taxes.
I know that that's not really a popular sentiment, but across the country, there are examples
of university starting to pay taxes and starting and stopping what many consider to be freeloading
through the 501(c)(3) status when you have it from the case.
Philadelphia, where you have Drexel, Penn, Jefferson, and Temple all claiming 501(c)(3)
status, they are not paying taxes and they are devaluing housing in their neighborhoods
and not allowing for a better tax base to increase to improve local schools and local
infrastructure.
So, there's so much that we ought to be doing this way beyond our individual research studies
or our practice opportunities we have.
There are other ways of getting the universities involved, and I wish you the best of luck.
I have been trying to do it at Drexel to not much success.
DR. ANGELA ODOMS-YOUNG: Yeah, I have one, we're going down to the final questions, but this
is a similar question about public universities.
The focus on food systems and they're generally land grants.
This is the opposite of Indigenous ways of looking at land.
How do you reconcile this?
Looking at where research tends to happen is hard to go back and it's hard.
It's very difficult to go back, back.
So, as we move forward, how do we create those equitable structures to make sure that we're
able to, as you talked about, address some of the needs by looking at structural determinants?
DR. MARIANA CHILTON: Oh, thank you so much for the question to go forward.
We have to go back and we have to acknowledge that a lot of the land grant institutions
were, those were stolen from native communities.
So the, you know, the land grant institutions need to work alongside go and share funding
where the Indigenous communities that are either still in place or that have been displaced.
I think about in Pennsylvania, the Pennsylvania land grant institutions should be connecting
with the (AUDIO DISTORTS) tribes that were dislocated or, you know, walked through various
terrible situations of Trail of Tears and to make reparations
and to really invest real money, and I'm not talking, you know, $100,000 Grant or $50,000
consulting type of thing.
I'm talking about millions and billions of dollars that ought to be going back to native
communities.
If we're going to promote Indigenous sovereignty, as Dr Jernigan talked about, we have to invest
in that.
And we, those of us who do this kind of work and who have some power in our own institutions
should be working to dismantle the current infrastructure that we have in our land grant
institutions.
So it is extremely necessary.
You can go back to go forward and there has to be a repayment and retribution, sorry,
restoration, not retribution, maybe retribution, but restoration to help people get, you know,
start to even infield.
DR. ANGELA ODOMS-YOUNG: Well, thank you so much, Dr. Chilton, for your thoughtful presentation
and your response to the questions and comments.
We're going to move into to our closing and so we appreciate your participation.
Thank you.
So, I would like to thank all of our panelists and participants today for sharing your expertise,
your research ideas, your thoughtful questions so we can have a better response to address
food insecurity.
We were able to explore what existing data is in place, understand and explore some of
the pathways that link food insecurity and health outcomes.
Also, talk a little bit about nutrition and security.
And then look at different sectors where we are, what do we know when it comes to interventions
in both communities and within the health care sector.
Tomorrow, please join us again.
We start at 12:30 Eastern for Day 2.
We'll start out with a recap of day one, and so tomorrow's agenda will also cover the neighborhood
food environment and its role in health outcomes, health disparities, and the role of how modifications
in neighborhood food environments can help promote health equity.
So, thank you again for participating and joining and we look forward to seeing you tomorrow. Have a good night.