DR. KAREN GLANZ: Everyone, good morning or good afternoon, depending on where you are.
Welcome to day three of the NIH Food Insecurity, Food Environment and Neighborhood Health Disparities
State of the Science workshop.
Today we'll focus on Implementation Science, Policy, Community-Based Research and exploring
what works, what doesn't work and why?
Yesterday, we had a series of wonderful presentations focused on the neighborhood food environment
and some evaluations of strategies to inform policy and practice that may improve food
environments and prevent diet related health disparities.
In reflecting on the talks that we heard yesterday, I want to call your attention to one cross-cutting
theme which has to do with correlation versus causality.
This I'm going to talk about it in the context of neighborhood food environments, but it
applies to food insecurity as well.
What I think is really important is that we align any interventions with our understanding
and with a good understanding of the causes of the problems, this problem is unhealthy
diet, risk factors, disease and so forth.
And also, that we calibrate the outcomes that we expect from interventions to realistic
expectations.
So let me give some examples.
There are many coexisting causes of unhealthy diets and risk factors and... ..to use the
example of a lack of supermarkets in the neighborhood or too many fast food restaurants, those aren't
the only causes or determinants out there.
Other determinants might include poverty, discrimination, issues related to housing,
transportation, crime and so on.
So, we're isolating the lack of a supermarket, let's say, as a cause of poor diet but it
doesn't operate in a vacuum.
And some of those things are measured and some of those things are unmeasured in our
research and for some of them we can get data from other sources at the neighborhood level,
from the Census, American Community Survey and so forth.
And I think that's really important when we think that the intervention of putting a supermarket,
for example, in a community in and of itself should bring about change when there are other
things going on in the background that are also important, potentially causal and may
be amenable to change.
Another example has to do with restaurant food environments.
We've seen a lot of interventions, a very active area has been calorie labeling and
policies for calorie labeling have prompted a lot of this research and that really acts
on the information environment within restaurants.
It's not the whole overall environment and the findings have been mixed about whether
or not calorie labeling affects people's food choices, purchases, and what they eat.
Another way to change the restaurant food environment that Chris Economos gave a good
example of with the Silver Diner study is menu changes, actually changing foods in the
environment.
And she took it one step further to go beyond availability and talked about defaults or
nudges.
So not only making the healthier choices available but making the healthy choice the easy choice
as we say in the behavioral economics or environmental change arena.
A third example that was presented yesterday by Joel Gittelsohn had to do with corner stores
and corner store interventions and anyone who's worked in this area in practice or in
research knows that one of the great challenges of trying to improve the food environment
in corner stores is not just to increase the access to healthier food, putting in some
fruits and vegetables, etc.
But to balance out the healthy versus the unhealthy because unhealthy cheap food is
often plentiful in these food settings.
And Joel Gittlesohn, with his years of work in this setting identified a lever that could
be potentially tangible which had to do with the food supply chain that the owners of these
stores did not have an easy way to get the healthier foods whereas they had very easy
ways to get the less healthy foods and so he's currently working on an intervention
to try to make a difference in that that they may really reshape the environment in
small ways and potentially in larger ways eventually.
So those are some examples about kind of looking at causation and not just correlation when
we're thinking about introducing interventions and evaluating them.
We also heard a lot about research methods and particularly about measurement of neighborhood
food environments and one important takeaway out of that was that our measures should be
aligned at the level of our leverage points for action.
So ground treating is very important when we use available commercial lists to identify
where different stores and food venues are.
Done a lot of research on that, we didn't hear too much about that research yesterday.
We're going to hear actually a little bit more about that today in terms of what people
encounter and Martin Caraher's talk gave the example of the crowdsourcing approach to food
locations in the community that people on the ground can help us to learn more than
just what we learned from a researcher's perspective.
So those are a couple of lessons from yesterday.
Today we're going to focus on implementation science and very specifically with two sessions
about what works and what hasn't worked and why?
In both food insecurity and neighborhood food environment.
I encourage you to listen closely and to think deeply about your own work.
Sometimes we get results that are disappointing or only partly successful and we're eager
to kind of present them as being more successful than they were without misleading maybe because
we've invested time, energy and funding from our funders to get these things done.
I would urge you to think about if something does not work or does not work as well or
on the outcomes that we expected to think about why that is, what we can learn from
it and how it can affect our collective efforts to try to improve health in the long run.
So with that I want to first remind everyone that you can add questions through the chat
box.
We love to hear your questions.
We have some terrific speakers lined up today and at the end of each panel we'll have time
for your questions.
And now it's my pleasure to introduce to you, Dr. George Mensah.
Dr. Mensah is the director of the Center for Translational Research and Implementation
Science at the NHLBI, the National Heart, Lung and Blood Institute.
And one of the things that I like about the name of that center is that the acronym is
CTRIS and so that's a really good leading to a workshop having to do with food.
Dr. Mensah will provide us with an introduction on implementation science.
Thank you, George.
DR. GEORGE A. MENSAH: Karen, thank you very much.
That was wonderful introduction.
I must say just listening to you go over what you've covered in the first two days just
shows how rich and how informative this workshop has already been.
And you are yet to even take a deep dive into panels five, six and seven where you tackle
the huge challenges of what works, what doesn't, why?
And also hear perspectives from community organizations of how we can do better.
So really, congratulations to all of you because this looks like has been a really terrific
workshop and I'm just delighted to have the opportunity to be part of bringing closure
to this three-day effort by focusing on implementation science first.
I'm glad that Karen liked the name of our center, actually, one of the original logos
that was proposed for CTRIS was after the fruit, so it didn't stick.
but we still we're still happy that people remember CTRIS.
And just by way of introduction, CTRIS was formed to serve as a strategic focal point
to...align and bring implementation science across all of NHLBI so that the discoveries
that we're making in heart, in lung, in blood, and in sleep research can be rapidly translated
into routine care.
So that's really the basis and so the implementation in our name we take very seriously.
I really want to thank Karen.
I want to thank Angela and Allison for giving me this opportunity to participate.
This is my disclaimer and disclosure slide and as you can see, I have no conflicts in
presenting and please don't take what I say here to represent an official position of
the NIH or the US government.
There is no question at all that most of what we're doing here today relies on the real
importance of our need for food and water.
This is just a cartoon that when the…in this effort to look at some 20 to 30
major challenges that we face.
It turns out that the need for food is really number one.
So, it's not a surprise that we pay a lot of attention to the disparities that are found
in this field.
You are all experts, and you all know the epidemiologic data that shows the stark realities
when it comes to nutrition disparities.
And some of the challenges of the neighborhood environment but the real issue for us today
is that there have been several global strategies that have been recommended and yet implementation
remains a major challenge and that's why focusing on the implementation science, it's important.
We need to try and distinguish implementation, the act of doing something, making it come
into being versus the science of the rigorous study of implementation.
So, in our center and across most of NIH, we define implementation science as a study
of rigorous methods to promote and to accelerate the integration of research findings and evidence
into policy and practice.
I've highlighted both policy and practice because it's not one or the other.
It's both clinical and public health practice but also to inform policies.
And that's critical because very often it's the policies that help sustain the clinical
and public health practices that were put into place.
Implementation science is really the big umbrella under which you find dissemination research
and implementation research.
So even though from time to time we tend to use implementation science and implementation
research interchangeably, they're not the same.
Implementation research is a rigorous scientific study of the use of strategies that lead to
adoption and integration of proven effective interventions or evidence-based health interventions
into routine day to day clinical settings, community settings in order to do what?
In order to improve patient or community or population outcomes.
Now dissemination research all goes hand in hand with implementation research because
that's the study of targeted distribution of information that comes out of all of the
research that you're doing, so that we can identify the best strategies, the specific
public health or clinical practice or population or community settings at the right channels
to distribute that information.
And the intent is to understand how best to spread and to sustain that knowledge and the
associated evidence-based innovations.
Now this is a very important slide and I've intentionally highlighted in blue many of
the themes that we look for when we are looking for meritorious applications, we should fund
within implementation science.
Now we all know that establishing efficacy and effectiveness is very important but it's
really not enough when we're talking about implementation science.
It's the field of dreams, a phenomenon.
The fact that you build it doesn't mean that would come.
And if nothing at all we've learned from the COVID era is that you can have an innovation
that's innovative, that's nearly 100 percent truly nearly 100 percent effective in preventing
death and 95 percent or so effective in preventing serious disease but we can't assume that people
would take it.
So, we must explicitly steady the implementation of that innovation.
What are the barriers?
What are the facilitators that can sustain uptake?
It's also important that we understand the context within which that innovation will
be accepted, will be adopted or will be modified and used as intended with very high fidelity.
Very important that we also assess and ensure that the innovations we are talking about
are not only available, but they are accessible to the intended population of interest and
especially that they're also affordable.
How do we have very broad reach for the intended population?
And then finally, we must study how to scale up, how to spread, what works and just as
importantly, to learn what doesn't.
That's why I'm very excited about the challenge before you today, learning from what doesn't
work but also learning to spread and scale up what's effective and what works.
Now within our center, this is the model that we try to remember every day.
If you look at the NIH's mission for biomedical research, we are across the entire spectrum
from fundamental discoveries to translation to humans, to translation to patients, to
translation to the bedside but we tend to focus on the real-world settings translating
our discoveries into real world settings used and dissemination and implementation research.
And very importantly, the big arrow going from right to left is to show that in fact,
there are many lessons we can learn from the work we do in implementation research that
can inform the earlier phases of research.
Here are a few examples of some of the design studies as you think about the challenges
you have today that can help enhance and sustain adherence.
I've highlighted bullets two and three because it's really critical, very much as Karen said.
Very often we're not talking about only one specific factor within the environment that
is responsible for the outcome of interest.
So thinking about the use of multilevel, multidisciplinary strategies that are really informed by dissemination
and implementation science frameworks that multiple frameworks that can really inform
the research designs that you put in place and regardless of which framework you use,
prioritizing the community engagement, community outreach and bringing in community stakeholders
early into the design to identify the important questions around food, food insecurity and
nutrition, the disparities and what will be important outcomes meaning outcomes important
to them not outcomes that we as academicians or researchers find exciting.
So, incorporating those outcomes to the most meaningful to the communities of interest
becomes very important.
I'm showing you here in this slide only just two examples of the frameworks that I used
in implementation size.
The RE-AIM Framework is really very important and several of the questions that are asked
reach, for example, what are your plans for reaching the population of interest?
Again, effectiveness.
How would you know that the intervention that you've just described that has been demonstrated
to be effective in a different context can be effective in the context that you study
in the particular neighborhood that you were working in?
And how about adoption?
How would you know that it will be adopted and used in the way it was intended where
it's original effectiveness or efficacy was demonstrated?
So really very important to have a framework whether it's theoretical or conceptual.
It's probably not as crucial as having the framework that guides the intervention that
you're going to be doing.
A second example is the CFIR which is the Consolidated Framework for Implementation
Research.
This particular model I'm showing here is one that's modified using advances in process
redesign, but these are only two.
There are multiple others that can be used.
A tip for you for those of you thinking about sending applications to us at NIH.
If you really want the application to be viewed as meritorious and it's really within the
arena of implementation science, there must be a conceptual or theoretical framework that
informs what you're doing and particularly for food insecurity, for nutrition research,
it helps to have that framework.
Now very often we do things in a very linear fashion as this slide shows going from left
to right, designing the steady very carefully making sure that the benefits to the population,
to the community, to the neighborhood that we're thinking about can actually be measured
and then making sure that people can have access and can adhere to the protocol that
we're using all the way to the end asking can it really work in this environment?
We work out all the kinks and then we say, well, let's then figure out what the dissemination
strategy and the implementation strategy should be.
We think that's the wrong approach and in fact, we must think of their implementation
strategies at the very beginning and the dissemination of strategies as well.
Who's going to deliver this intervention you're talking about in this particular community
of interest?
And how well does it fit socially, economically, culturally, within that community?
So, the social determinants of health put in the appropriate context at the very beginning
is really crucial.
And of course, it always helps when you build in some elements of training, of support, elements
of adherence, all critical parts.
But please let's not think of the implementation and dissemination at the end.
Let's think of it even at the beginning so that we can design effective interventions
for sustained impact.
Implementation science, as you all know, is a relatively new field. Although, we now have
a very well respected journals, there is at least...several very good authoritative books
and I'm just showing two here.
You know, a 10-minute presentation can't go into all the important resources available
for this field.
But we strongly encourage you, no matter what your special interest is, thinking of implementation
would help us. It is really not acceptable that the best interventions we have still take
on average 17 years to get into routine day to day care.
And that's for the clinical biomedical setting, where very often we don't have as many social,
cultural, linguistic challenges as we do when we start to talk about diet and nutrition.
So, really very important that we become fully engaged in the discussions you are having today
about the importance of implementation, the importance of how innovations work, why they
don't work, and what we can learn from them.
In addition, I've shown you here and these are hyperlinked on the slides that will come
to you the resources available from NIH website, including our major landmark PAR, program
announcement.
And certainly, we also have the classic R01 mechanism where if you have ideas, particularly
mechanistic approaches, to help explain why some innovations worked, and others didn't
work, we always welcome investigator-initiated research to help advance this field.
Let me conclude by saying it's we all know it's really essential that the effective innovations
you are helping design be widely adopted and scaled up and spread to the communities who
need them the most.
That's where implementation science helps.
And that's why we have to invest in implementation science.
We also know that innovations that went well in one community may not necessarily work
well in another, we need to know we need to study in a rigorous fashion, what works well,
where and why and when it does.
And that, again, is why implementation science is a really real benefit.
We need to understand why some interventions fail.
This is an excellent example where failure can be turned into success.
Because by knowing why things fail, we can plan our next interventions much better.
We can't do this alone.
So, collaborations are critical and are particularly forming strategic collaborations among community
organizations within academic health centers, and not forgetting about our policymakers.
Because making sure that very early on they know what we're doing so that when the results
come out, they can inform the policies that can help sustain the innovations would be
critical.
So, in sum...you can tell that implementation science is really fundamental to addressing
our health challenges, our health disparities, challenges, and helping advance health equity
because it can help identify the barriers, the facilitators, that would enable us to
have successful strategies that would really go for long term sustainability.
This is my final slide, and I want to show that, please visit us on our website.
And again, you can...also follow our official Twitter site.
Very often when we have important implementation science publications or important implementation
science, innovations, and strategies.
We tweet about them here.
So, let me stop and turn it over to Karen.
Thank you very much.
DR. KAREN GLANZ: Thank you so much, Dr. Mensah, for your thoughtful comments.
It's so relevant to the next session about the critical role of implementation science
and understanding what works, what doesn't work for who and why, and the critical role
of community and policy makers and their engagement in this type of research in addressing the
issues at a population level.
Our next session is exactly that.
We're going to focus in session seven, on what is what has and hasn't worked to address food
insecurity and health.
Our objectives of this session are to highlight efforts by one of the largest charitable hunger
relief organizations in the U.S. to discuss strategies.
To address food insecurity among high-risk populations in the context of the social determinants
of health, that influence implementation, and waste, improve these interventions, describe
positive effects or lack thereof, and the terms of research methodology and interventions,
assumptions, and features.
And then to examine research methodologies and interventions to explore what's worked,
what hasn't worked, including case studies of effective interventions as well as future
opportunities.
This is a two part session and we have the opportunity to hear from as was mentioned,
one of the leading hunger relief organizations in the United States, Feeding America, to kick
off this session, I'm delighted to introduce Gita Rampersad, who is the Vice
President of Health and Nutrition at Feeding America and a close colleague who will provide
an overview of Feeding America's efforts. During this presentation, as we talked about before,
feel free to enter your questions in the chatbox, any comments that you have, and then we'll
move into the second part of the presentation where we have a panel.
So, I'm going to turn it over to Gita.
DR. GITA RAMPERSAD: Good afternoon.
I'm Gita Rampersad, and I'm here on behalf of Feeding America, I have no conflicts or
disclosures.
For those of you who aren't familiar, the Feeding America network is made up of close
to 200 food banks and over 60,000 food pantry and meal programs across the country.
We also have two national offices.
One is in Chicago and the other one is in Washington, DC, where I'm located.
The way the Feeding America network works is the Feeding America purchases or acquires
surplus food from public and private sources.
In turn, makes it available to local food banks, who then distribute it to the over
60,000 meal partners that they have in their communities, which results in 1 in 7 Americans served.
Last year, we helped 40 million people in America by providing over six and a half billion meals
and by rescuing close to five billion pounds of food that would have ordinarily gone to waste.
In addition, the food banks are often involved in SNAP application assistance.
And that was a year last year was an incredibly busy year for us too.
This is a slide that shows the numbers for hunger in America in 2019.
In 2019, there were 35 million Americans struggling to afford the food they needed.
And about 11 million of those 35 million were children and 4 million of them were seniors.
You know, the positive piece on this is that we were really moving the needle on hunger
in this country
prior to COVID-19.
We were seeing record lows in terms of food insecurity rates, the rates that we hadn't
seen since before the great recession.
One thing that we are continuing to see are disparities in hunger.
People of color are more likely to face hunger.
One in 13 white households face hunger, as compared to one in six Latino households, one in five
black households, and one in four Native American households that report being food insecure.
We also know that COVID-19 has had a disproportionate impact on people of color facing hunger.
They faced higher rates of unemployment, hospitalization, disease, and death.
At Feeding America, we projected that COVID-19 was going to have a significant impact on food
insecurity for 2021.
We estimated that 42 million people would be considered food insecure as a result of
the pandemic in 2021 including 13 million children.
Additionally, the numbers were going up for those who would experience very low food security.
And that means that they would be relying more heavily and regularly on the charitable
food system.
Another way to really kind of conceptualize hunger in America is, you know, to follow
this slide.
Before COVID-19, 1 in 9 people faced hunger in this country and 1 in 7 children were food
insecure.
Pandemic made some drastic changes to those numbers.
Last year, we saw that those numbers shifted to one in six people who are facing hunger
and one in four children.
We also saw record numbers seeking help from the charitable food system.
Our food banks reported a 60% uptick in the number of clients served last year and also
reported that roughly 40% of the individuals that were being served had never had to have
to rely on the food on the charitable food system before.
For us, we are always focused on research that serves the charitable food system and
informs national thought leaders.
And one of our colleagues, Dr. Waxman, will be leading the forthcoming panel.
And it's always for us at Feeding America, it's always important that we recognize our
research partners because we know that we can't do this alone,
and our goal is really to enable our food banks to understand and more effectively serve
the food insecure populations in their communities.
This is one of our research tools.
This is a Map the Meal Gap.
And this is the 2019 version of Map the Meal Gap.
And what it's showing here is that hunger is ripe with what is ripe with an equity. Where
you live matters.
So, if you live in the south, in the southern region of the United States, you are more
likely to experience higher levels of food insecurity.
Hunger also pushes people to have to make tough choices.
We know that for people that we serve household income doesn't cover basic needs, we see that
there's, you know, close to 70% having to make tough choices between paying for utilities
and food, transportation and food, medical care, and food and almost 60% have reported
having to choose between paying for housing and food.
And for me as vice president of health and nutrition, very concerned about the reality
that people have to make a medical care decision over a food decision.
In other words, somebody may have to choose between whether they can purchase their insulin
for the month or feed their family.
These tough choices lead to really an unhealthy cycle.
When our households are faced with these tough choices, they often have to stretch a budget
and purchase inexpensive unhealthy food.
And as you can see close to 80% report having to do that processed food and that you know
sort of eating in excess of processed food can often lead to fluctuations in weight and
blood sugar, which then in turn actually turn into full blown chronic conditions like high
blood pressure, heart disease, diabetes, and obesity.
In fact, one in three households in the Feeding America that served by the Feeding America
network report a member living with diabetes.
This also has an incredible impact on the U.S. healthcare system.
In a study that we did with our partners at the University of California, San Francisco,
and help Dr. Hilary Seligman, we found that for every food insecure person in this country,
you can add an extra 2,000 dollars of healthcare costs to their annual expenditures.
And you know, when you multiply that by something like 35 million, we're talking about 70 billion
dollars that we think could be saved.
One thing we always are talking about at Feeding America are where are the research gaps and
opportunities and I wanted to just, you know, highlight a few of them today, those being
data disaggregation, hunger, and health, and nutrition security.
I think we need to do better at disaggregating data.
And we need to begin with, you know, race, ethnicity, and language and go from there.
We're currently in the process of doing that for food security.
We've certainly identified many drivers of health and disaggregated those data by race.
But it's important to be able to see exactly who is you know, sort of realizing the most
need so that we can tailor our resources and our services to make sure that we can correct
that.
The other gap an opportunity area that are highlighted here is hunger and health.
I think it's important we continue to strengthen the messaging that there is a strong connection
between hunger and health, through our programs through some of our policies, and definitely
through some of our best practices.
And finally, we are currently in discussion around this, this term this hot topic nutrition
security, and for Feeding America, we're working to define what nutrition security means for
us and for the charitable food system, and how we can measure it.
So... going back to COVID-19, on the one hand, COVID-19 created the perfect storm, and you
know, it up ended the need for food assistance, and it created unchecked rates of disease
and mortality.
But it also open doors to new opportunity.
And there is overwhelming interest in the intersect of hunger, health, and I will say
equity in this country.
And it's time, you know, this is our moment, this is our moment to really capitalize on
this interest, partner and collaborate to overcome hunger in poor health in this country.
I always like to put this slide in my presentations, because I think it's a really clear example
of the disparities that exists.
The racial disparities exists when we talk about hunger and health.
So, this is a map of Georgia. In the middle, it's broken down by county. In the middle
is the is the percent of black people living in different counties.
And the deeper the shade of red, the higher the black population in that area, in those
areas.
On the left side is the Georgia Map the Meal Gap.
And then, again, the deeper shades of green indicate higher rates of food insecurity.
And then on the right side, we have the map of Georgia representing COVID-19 deaths.
And red indicates the highest rates and then the darker shades of blue indicate the next
highest rates and so on.
And I think it's pretty, clear here that there's a pattern and, you know, that really is sort
of making a case for health equity.
And you know and should not be ignored.
And I think you'll hear from Adam in during the panel, who will talk about how COVID-19
has impacted food insecurity for the state of Washington.
So, you know, what is our, what's our vision? What how are we going to advance health and nutrition
given the, you know, the changes that the pandemic has brought in think, we've decided
that we need to be very, we need to be bold, we think that we can make a measurable impact
on the health and well-being of all communities we serve.
But we can't do this alone.
We know that we will need to partner, and we are partnering to be innovative and able
to ensure equitable access to nutrition to nutritious food.
Part of our commitment last year to change was to really focus in and prioritize equity,
diversity, and inclusion and that includes health equity.
So, at Feeding America, health equity means all people facing hunger have a fair and just
opportunity to be as healthy as possible across the lifespan.
And we've adopted our definition from the Robert Wood Johnson Foundation.
I wanted to add this slide because this is gives you a good picture of how we are sort
of narrowing our focus areas to be able to close gaps and advance health and nutrition
for people facing hunger.
We're very focused on healthcare partnerships in order to be able to view food as medicine
and develop programs and best practices relevant to that concept.
We I think a minimum of 50% of our work could probably be categorized as health and nutrition
equity.
So, we're doing a lot of work.
There's a lot of momentum around equity when it comes to health and nutrition.
And you'll hear from Dr. Schwartz and in the panel around some of our best practices, specifically
the HER guidelines that we're very proud of and how we are transforming the charitable
food experience.
I wanted to also add a few examples of food banks that I think are you know, really kind
of push moving the needle on hunger, health inequity.
I'm not going to go into these initiatives in detail but just know that there's, you know,
this is just a handful there, there are a lot of really innovative projects that are
being that are taking flight across our network.
And I think you'll also hear from another panelist, Dr. Caspi, about how food pantries
are also doing their part to transform the charitable, food experience, and particularly in examples
in Minnesota.
So, before I leave, I just wanted to, you know, sort of mention that I think what
we're seeing here overall, you know, very much due to COVID-19
and our public health crisis is a shift.
We're no longer really just thinking about things in sort of health and nutrition terms,
we're really shifting towards more towards population health improvement. Our donors
are no longer considered donors.
They're our partners, they're our collaborators.
They're at the table with us designing these programs and interventions.
And they're accountable just like we are.
We also are moving away from our pilot programs, we've done a lot of exploratory work in health,
nutrition, and we're now doing, you know, we're now engaging in designing high impact
models and interventions.
We're also not thinking about things in terms of just feeding people, I mean, nutrition
security is a real deal.
And so is food justice.
And so that's, you know, we're starting to think more broadly about our impact in those
areas.
And we're also thinking about people slightly differently, people facing hunger, or you
know, are not really being thought of in terms of like, you know, what chronic condition
goes along with that, as we know, many people facing hunger have higher rates of chronic
disease. We're going in with a whole person approach, so to health, because physical,
just looking at the physical is not enough.
We have to think about the mental and the emotional well-being.
And then finally, we recognize that we have to meet people where they are and continue
to center people facing hunger in this country.
It's never going to be a one size fits all.
So, we thank you for your time, and I welcome you to join us and join me on this journey
to end hunger.
Thank you.
DR. KAREN GLANZ: Thank you so much Gita for sharing the work of Feeding America.
We're going to move into our panel and then Gita will return during the Q&A.
So, I've already seen some questions in the chat for Gita and so she'll be back at the
end of the panel and we'll have a robust discussion about strategies to address food insecurity
and think more about what works and what doesn't.
I'm going to turn it over to Elaine Waxman.
We're thrilled to have her as the moderator for this session.
Dr. Elaine Waxman is at the Urban Institute, and she has done extensive work in food insecurity
and looking at the determinants, as well as the consequences of food insecurity.
And so, I'm going to turn it over to you, Elaine.
Thanks.
DR. ELAINE WAXMAN: Great.
Thank you so much, Angela.
So, in this panel session, we're going to explore some of the research methods and various interventions
that can help us shed light on what has worked and what hasn't worked, and why.
So, we have three panelists, and then we will have an open discussion at the end.
I would encourage you to enter questions into the Q&A box at any point that something strikes
you during the presentations, or again as we come back together as a group.
So, our first panelist is Dr. Marlene Schwartz from the University of Connecticut, and she's
going to talk with us about her study on Nutrition Standards in the Emergency Food System.
We will then hear from Dr. Adam Drewnowski of the University of Washington, and he will
address Food Insecurity in the context of COVID-19.
And then Dr. Caitlin Caspi from the University of Connecticut will be our final speaker,
and who will address Food Pantry Transformations in Minnesota.
And then, as Angela mentioned, Gita Rampersad will join us at the end and we'll have a group
discussion.
So we'll begin now with Dr. Schwartz.
DR. MARLENE B SCHWARTZ: Hello, my name is Marlene Schwartz, and today I'll be sharing some research
we've done on the topic of Nutrition Ranking within the Charitable Food System.
So why focus on nutrition in this setting?
Well, one reason is because it's important to clients.
A few years ago, as we were beginning this work, we surveyed clients from several food
pantries and asked them about their preferences for different types of nutrition interventions.
And one of the questions we asked was to indicate the most important reasons why they choose
certain foods at the pantry.
And as you can see, nutrition was the most frequently cited reason.
So, if the goal is to ensure that the nutritious foods that clients want are available to them
at the pantry, what can we do to shift the entire system toward more of these foods?
This conceptual scheme illustrates several components of the charitable food system,
and the elements are represented by gears in order to communicate that as one setting
makes a change either in the foods that are donated or selected, it will affect the other
settings and people's choices.
But in order to assess changes over time, we need a way to measure the nutritional quality
of the food, and that's where a nutrition ranking system comes in.
One system that was specifically developed for food pantries is called SWAP, an acronym
for Supporting Wellness at Pantries.
It's a stoplight system, as you can see, and it also incorporates behavioral nudges, such
as organizing the food on shelves so that the green options are at eye level and communicating
nutrient information along with the color-coded signs.
One of the first studies we did testing SWAP was to see if implementing it changed the
inventory in a food pantry over time.
So, we worked with six food pantries in Connecticut.
We helped them implement SWAP.
And before we started, we collected data on their inventory for four weeks.
We went in and looked at all of their food, put it into categories, and ranked it as green, yellow, or red.
Here are the baseline findings.
One of the things that's interesting is that a large portion of the foods available were
vegetables.
And another interesting thing was that the combination meals were the category that seemed
to have the largest proportion of red foods.
So, combination meals are things like soups, stews, macaroni and cheese, and frozen entrees.
Here are the findings a year later, we used regression analyses and found a significant
increase in the availability of green foods overall, but no significant changes overall
in yellow or red foods.
It is interesting to note, though, that if you look at the combination meals, there was
a decrease in the proportion of red foods in that category.
So, the next study we did was designed to look upstream at the effect of nutrition ranking
at the food bank.
So, we were working with a food bank that had been ranking their food for a number of
years, and initially, it was done internally to really help them understand their own inventory and make some purchasing decisions.
But after a while, they decided to share this information with the food pantries. Here's a screenshot of the ordering platform that the food pantries used when they got
food from this food bank, and what they did was add a column that says, nutrition description, and it had green, yellow or red listed.
So, people shopping could easily see the nutrition rank of the food they were ordering.
So, this happened in April of 2019, and it provided an opportunity for us to compare
the ordering of the pantries before and after they could see this information.
So, to test this hypothesis that seeing the nutrition rank would shift ordering behavior,
we used an interrupted time series analysis from the 25 largest pantries and all of their
orders, so it was about 64,000 ordering records.
And we compared what they ordered during a 15-month baseline period and then a 14-month
intervention period.
So, after the nutrition rank information was available, there was a significant increase
in the average monthly orders of green foods.
You can also see that the orders of red foods decreased over time.
However, this began prior to the intervention and we were able to look at the food actually
available for the pantries to select throughout this time period, and found that that decrease
in red food was really attributable to a decrease in red foods available at the food bank.
So, the last study I'll share today was done when a food pantry decided to implement the
SWAP system and wanted to assess whether it was associated with a change in the foods
their clients selected.
So, we went to the food pantry before they made any changes.
We collected data from about 120 clients over a few days.
Then SWAP was implemented over a holiday weekend.
We waited a couple of weeks and went back and collected data from about 100 clients.
Here's the baseline data, again, lots of fruits and vegetables, as seen on the left.
And interestingly, a large portion of the combination meals were rated red.
After SWAP is implemented, the overall profile of the baskets improved with a significant
11% increase in the proportion of green items and a significant 7% decrease in the proportion
of red items.
Looking closely by category, it seems that the increase in green items was driven by
an increase in green fruits and vegetables and also an increase in green dairy, while
the decrease in red was evident in the drop in red fruits and vegetables and the drop
in combination meals.
So how realistic is it for food banks all over the country to implement nutrition ranking?
Well, the good news is back in 2017, the anti-hunger organization, MAZON, conducted a survey of
all U.S. food banks, and one of the questions was whether they use the system to track their inventory.
And the responses indicated that 54% were using some type of nutrition inventory tracking
system, although there were quite a few different systems in use.
So that highlighted a challenge, if there's going to be a national effort to shift the
nutrition quality of the food throughout the charitable food system, it would be helpful
to have one set of nutrition criteria that everybody was using.
So that was the impetus for the Robert Wood Johnson Foundation's Healthy Eating Research
Program to create an expert panel to develop nutrition guidelines for the charitable food
system.
Director, Mary Storey, and deputy director, Megan Lott, invited this group of experts
to work together to develop a set of nutrition guidelines, and Hilary Seligman and I co-chaired
the panel.
It's notable that the members included both researchers and people who currently work
in food banks.
So, we faced the challenge.
On the one hand, the guidelines needed to be supported by scientific evidence.
We reviewed existing guidelines from the charitable food system, government, and industry, and
we anchored all of our decisions in the 2015-2020 Dietary Guidelines for Americans.
On the other hand, the system we developed had to work within the charitable food setting.
So, we took a number of things into account, a couple of them were limited capacity to
add staff time or increase costs, and also the reliance on volunteers.
So the system needed to be straight forward enough that you could train volunteers to
use it accurately.
Finally, we were able to give a draft of the guidelines to a national task force that Feeding
America put together, made up of food bank staff, and they provided detailed feedback
for us, which we were able to incorporate into the final version of the guidelines.
The first step in ranking of food is to place it into one of these 11 categories.
I will note that the last two categories remain unranked.
The committee felt that it was important not to rank condiments and cooking staples, because
on their own, they typically wouldn't rank very well.
But they really are used to prepare meals at home, and we wanted to make sure that we
were not in any way deterring people from taking these foods and using them in their
own cooking.
We also decided not to rank what we call miscellaneous items.
So, these are foods like baby food or nutritional supplements that typically have a very specific
audience.
The second step is to identify key nutrients using one serving based on the Nutrition Facts Label.
So, the three nutrients that you want to focus on are saturated fat, sodium, and added sugars.
The third step is to take the specific values of saturated fat, sodium, and added sugar
and apply them using this chart to determine whether the food ranks as, choose often, choose
sometimes, or choose rarely for that nutrient.
You then determine the overall product's ranking as the lowest tier of any of those key nutrients.
So, the final version of the guidelines was released in March of 2020, and the full report
is available on the Healthy Eating Research website at the link that's listed below.
They've been really well received, and it's been really exciting to see how different
organizations have taken the guidelines and incorporated them into the work that they
are doing with communities.
Thank you so much for your attention.
DR. ADAM DREWNOWSKI: Hello, everyone.
My presentation today will be about addressing food insecurity in Washington State in the
context of the COVID-19 epidemic.
I will try and stress the importance of collecting local data at its fine granular level as opposed
to relying on national data to drive local interventions.
Let me show you the difference here.
First of all, in the last couple of weeks, the USDA Economic Research Service released
a report on Food Insecurity in the year 2020.
These were data based on the United States Census collected in December 2020 for a representative
sample of 34,000 households.
Food insecurity was assessed over the previous 12 months.
The results showed that food insecurity was estimated to affect 10.5% of households, and
that prevalence remained essentially unchanged since...
2019.
But looking within the USDA report, you can find huge social disparities.
Higher prevalence rates were observed among households with children, black and non-Hispanic
and Hispanic groups, and among the unemployed.
There are also further disparities by income.
So, in this slide, I reported USDA data by year, and notice there is not much of an effect
between 2019 and 2020.
When you start looking at social disparities, you find huge differences.
Let's start from the bottom.
Poverty to income ratio.
We're looking at the lowest incomes at the bottom and the prevalence rate of food insecurity
is in the order of 35%.
This decreases somewhat as income goes up and plunges to about 5% or under with incomes
at twice poverty.
Then notice the data for female head of household, no spouse, here approaching 30%.
Data for black non-Hispanic and Hispanic groups.
And what I'm showing you at the top are local data by state, Washington State compared to
Washington, D.C., compared to data from Louisiana, Mississippi, and West Virginia.
Just this selection to show that food insecurity can go from 5% prevalence to 35% prevalence,
depending who you are and where you live.
So, the national data 10% to some extent, mask, some of the very profound local disparities
by neighborhood.
And this is where we come in.
Since last year, we have been engaged in mapping food insecurity within Washington State.
There were three online surveys, WAFOOD1, June-July of last year, WAFOOD2, December
of last year-January of this year, and then most recently, Summer 21, WAFOOD3.
These were all online surveys, not representative.
To the contrary, these were surveys of the most affected groups.
Our samples were mostly female, 81%, with children under 18, 40%, and with incomes below
$35,000 per year for the household.
30% of our population was low income.
Our data were also coded by county and also by zip code.
So, when you start looking at the map and the bubble graph on the right, you start realizing
that within Washington State, the prevalence of food insecurity was not the same across
all counties.
In fact, there was a socioeconomic gradient that you see on the bottom-right, with median
household income by county, related weekly, but related nonetheless to food insecurity
observed in the WAFOOD surveys by county.
Let's move on here to show you the same gradient that the USDA found out.
So here we look at, from the bottom, the lowest income group, $15,000 per year, that's below
poverty.
And notice how food insecurity goes up with lower incomes and goes down as incomes increase.
Here we see a difference also for families with children and those without, more affected
are families with children.
There's a big difference by race-ethnicity.
And there's a huge gradient by education, higher rates of food insecurity among groups
with high school education and some college.
The data I'm showing you are for WAFOOD1, July, and WAFOOD2, December.
By December, the initial shock wore off a bit and the data on food insecurity was somewhat
attenuated compared to what we found in the early months of the epidemic.
Same gradients as before, but here our numbers are much higher because, of course, our population
is lower-income, mostly female, mostly with children.
So here, we're also finding the link between food insecurity, diet quality, and food expenditures.
So first of all, all households reported reduced access to food in WAFOOD1, that was the time
to remember of some food shortages.
And notice that there is a big difference between the food secure households who don't
seem to be too worried and food insecure households who are very worried about access to meat,
and chicken, and milk, and yogurt, and other foods, including fresh fruit and fresh vegetables.
What we find is that access to those foods was actually related to spending.
So here we have, again, from WAFOOD data file, estimated food spending, foods away-from-home,
and foods at home during the pandemic, before the pandemic, and again, we stratified by
food security.
So here the total food spending would be in the order of $50 to $60 per capita per week
and $200 to $240 per month.
Notice that there is a big difference in terms of spending between the food secure and the
food insecure respondents.
What was very striking here was that the food away-from-home pretty much halved or not disappeared
completely, but certainly, food spending on food away-from-home was reduced, not surprising
at the time a lot of the restaurants were closed.
So here we have detailed data on food spending.
Contrast those with national data, we're seeing the food secure and very food insecure households
are spending the exact same amount estimated $50 for the medium per week.
We find much finer gradations on food away-from-home with at-home and big difference by food security.
Of course, eating habits changed.
We knew that from before.
And there was a greater reliance on rice, and beans, and peas, and legumes and packaged,
boxed snack foods, bread, and so on, and the quality of the diet was reported as reduced.
Many of our respondents said their diets had gotten worse and the majority, 64%, noted
rising food cost.
And so to summarize, based on the results from WAFOOD1 and WAFOOD2, we estimated the
mean prevalence of food insecurity to approximately 30% in a WAFOOD sample.
Note that we're looking at 30-day prevalence, not a year of the prevalence, but 30 day prevalence
of food insecurity.
And our sample was, as I said before, largely female, largely lower-income, and with children.
Not surprisingly, we found more food insecurity among the newly unemployed, households with
children, and minorities, and we linked food insecurity to lower food expenditures and
to reduced diet quality.
Let me emphasize here, you'll be hearing more about this in the session that food assistance
played an enormously important role.
And this was not only federal food assistance, SNAP and WIC programs, but also food assistance
and the state and local level.
And let's not forget about the food banks and charitable initiatives, which played a
critical role in alleviating food insecurity among our respondents.
But let me now get back to neighborhoods (INAUDIBLE) maps.
You will appreciate that fine-level geographic resolution unmasks social disparities by area.
So, when you look at, for example, state-level obesity rates, the difference is between 20%,
25%, 35% by state.
But the moment I start looking at obesity by Seattle neighborhood, I uncovered gigantic
differences going from 5% obesity to 35% obesity, depending on where people live.
So, the map on the right shows you modeled obesity rates in Seattle at the unprecedented
census block level.
Notice there is more obesity by the freeway and virtually no obesity among the waterfront
estates.
DR. ADAM DREWNOWKI: It all has to do with socioeconomic status, and more pointedly, the value of your
home.
So, our question was whether the same gradient would be observed with food insecurity.
And...our results show, yes, we found the same exact gradient.
Just to walk you through the logic, on the left you see the components of a deprivation
index, the famous SEN index.
Deprivation at census tract level based on census data, which include poverty, income,
single-parent families, housing, education and employment.
The very same factors which were driving higher rates of food insecurity.
We were able to plot prevalence of food insecurity by zip code, because our respondents.
Were geocoded by zip code, and you can see similarities, there is more food insecurity
in the more deprived neighborhoods.
So, deprivation, reduced budgets, unemployment, bad social conditions lead to more food insecurity.
But there is more.
What we were able to do is to join some of our data with the dashboard produced by King
County for COVID risk, COVID infections, and even COVID mortality.
So, what you see here on the left is our map of property values by zip code from the WAFOOD
studies.
What you see in the center are data for COVID positivity from Public Health Seattle King
County dashboard.
The two maps are mirror images of each other, and the map on the right shows you COVID mortality
also from Public Health Seattle King County.
And I would argue there's also a relation.
So sometimes we say, you know, the virus does not discriminate.
Of course, it does.
Food insecurity, deprivation, COVID risk and even COVID mortality are absolutely related
to the underlying social structures and the wealth, or more to the point, the deprivation
of neighborhoods.
So, I'm going to stop here.
Thank you for your attention and I'm going to now be able to answer some questions.
Thank you so much.
DR. CAITLIN CASPI: Today, I'm going to talk about SuperShelf, which is a collaborative partnership across
a number of organizations in Minnesota.
And what SuperShelf aims to do is to transform food pantries to be more welcoming environments
for clients to access healthy and appealing foods.
So, my colleague Marlene Schwartz, gave a background on the need for and the current
efforts around obtaining and distributing high quality food in the charitable food system.
And I'll add that when we survey clients across the state of Minnesota, they overwhelmingly
indicate that they want healthy foods like fruits and vegetables, but they can't take
what's not available, and they probably won't take food that is not fresh and appealing.
So, a lot of the work of SuperShelf is in working on both the supply side and the demand
side.
So, in the SuperShelf intervention, we focused mainly in these two areas.
So, the first is in increasing food supply, not using a tool kit approach, but actually
having a consultant that works with the pantry over several months, to increase the sourcing
of high quality foods and the variety of healthy foods.
And then after that stuff is done, it becomes a focus on increasing the appeal of the foods
that are offered using behavioral economics.
So, the whole food pantry is organized into food groups like a grocery store, and the
healthy food is made prominent and appealing.
So, this is an example of how the food that people are allowed to take changed before
and after the SuperShelf intervention.
So, before you see the first two items that clients were offered when they walked in were
pancake mix and pancake syrup.
And these were offered to everyone first thing, and then after the first items are fruits
and vegetables.
So frozen fruits and vegetables and then unlimited fresh produce, and the pancake stuff is still
there, but it's offered when the cart is full at the end.
This is a visual of the transformation that the pantry makes before and after, where everything
is organized by food group and it's arranged appealingly and it's really displayed like
it would be in a grocery store.
So maybe you can see in the slide on the right.
The whole grains are at eye level and there's clear signage throughout.
So, we evaluated this intervention in a cluster randomized study, where we were selecting
16 food pantries, and we're randomized to the intervention or delayed intervention condition.
I mean, the delayed intervention they did transform, but not until we finished all the
data collection.
So, we collected data in two waves of eight pantries each.
And I do want to note that in the final five pantries, we couldn't collect measures that
required in-person visits because of COVID, and the food pantries changed their operations
and closed during this time.
We collected many measures in SuperShelf, at the client level and the pantry level,
and in all these measures, we collected data at baseline and then one year follow up.
So, the measures I'm going to focus on today are the ones that we assessed by HEI, or healthy
eating index.
So, we have data that we collected from client dietary recalls, from client carts as they
selected food from the food pantry, and then of the inventory of the food pantry.
So, the healthy eating index score is a measure that has a maximum score of 100, and it's
comprised of 13 subcomponents.
And overall, it measures the degree of alignment between a set of foods and the dietary guidelines
for Americans.
So, a higher score is going to indicate better alignment with the 2015 to 2020 dietary guidelines.
So, the results that I am going to present are based on a sample of choice-based food
pantries that were selected to be part of the evaluation.
And they are located across Minnesota in urban and rural areas, and the client level data
is based on 316 clients.
The majority of whom were female and white, as may be typical of clients across the state
of Minnesota.
These are the HEI scores at all three levels.
So, the food pantry inventory HEI score was 65.1, which is higher than the scores for
the food selected by clients of the pantry, which is higher still than the diet quality
score for clients.
But I want to put these numbers a little bit into context.
So, the HEI score in 2015 for the whole US food supply was about 55.
So, the total score for inventory is really not low by comparison, but there's still definitely
room for improvement, especially when we look at the subcomponents.
So, we made this radar plot to visualize the subcomponents, at each of the levels inventory
in red, client cart in orange and dietary recalls in yellow.
This is again for our baseline scores.
We see that for subcomponent scores of inventory, many of them are quite high, but it's not
across the board.
And that subcomponent score is particularly for refined grains and dairy are really quite
low.
And then when we look at the diet quality subcomponent scores for client diet based
on the recalls, they're almost uniformly low.
So now we're going to look at pre/post change results, so in the 11 food pantries where
we have complete data, we measured implementation on a 100-point scale.
That includes four subcomponents of change, and our measure of implementation suggests
that the SuperShelf transformation was feasible and well implemented as it was intended in
the transformation group, and there were very few changes in the delayed transformation
group.
So, in the transformation group, we saw changes in our subcomponent measures that included
the number of healthy foods stocked, healthy and unhealthy food placement, as well as aesthetics
and layout.
When we looked at pre/post change in our three HEI measures, we didn't see any statistically
significant changes over time in the transformation group, compared with the comparison group.
You will note that we did see a six-point increase in inventory HEI scores, but again,
this wasn't statistically significant compared to the comparison group.
And in the other measures, we really didn't see much change.
Even though diet quality score didn't change, clients did notice the change, and they were
reporting higher satisfaction after the intervention.
So, on the survey, we saw statistically significant increases, compared to the delayed intervention
in how clients were reporting the food selection.
They were more pleased after the intervention.
And then when we were asking staff and volunteers in qualitative interviews what changes they
noticed.
They were also remarking on the clients who were saying that they were happier, and they
were appreciating the changes that they saw.
The interviews with food pantry staff and volunteers also showed that they were really
satisfied with the changes.
And I think this is notable because food pantries are low resource settings and they can't always
implement change and sometimes, we've seen that they've had trouble buying into the notion
that clients want healthy food.
So indeed, one of the quotes from our interviews said, we weren't going to spend our money
on whole grains and brown rice because people don't like those anyway, which is not true
from what we're finding.
And they were also noting other aspects of SuperShelf beyond the nutrition that we're
really working for them, notably creating a friendly and positive environment, and appreciative
of the effect that that could have on their clients.
So, the key points are that the intervention was feasible to implement and that clients,
food health managers and volunteers were satisfied with the changes.
However, we didn't see that it resulted in changes in healthy eating index scores, but
we can think of some reasons why this might be the case.
So first, HEI scores were pretty high at baseline, so there might have been some sort of ceiling
effect in our measure.
And then also clients were still constrained in what they were allowed to take at their
visit.
And so that sort of, it makes me want to ask what would happen if clients were really allowed
to shop as they would in a healthy environment without constraints?
What kind of behavior change might we see then?
And then finally, in this study, we didn't really account for the food that people were
getting outside of the pantry, and we know that's going to be a substantial portion of
their diet.
So, all this being said two opportunities I want to pay particularly close attention
to is, first, any opportunity to look at food obtained inside and outside the food pantry
in the same study.
So, I think particularly looking at the interaction of what people buy, maybe even with their
federal nutrition benefits like SNAP, and what they obtain at the pantry, in total,
that's going to tell us more about where we need interventions, and so kind of the cross
collaboration between the retail sector and the charitable food sector.
And then also, I think there are a lot of opportunities in new models for food pantries
that are emerging post-pandemic.
So, in the last month or so, I've talked to two food pantries in Minnesota that are opening
with no restrictions.
So, clients can go as often as they want, and with almost no exceptions, they can take
anything.
And as much of anything as they want.
And I think what this does is it offers an opportunity to look at the positive effects
of a food pantry visit and its potential to help people beyond just nutrition, including
outcomes like connection with community resources and reduce stigma, which we know are really
important for food insecurity.
DR. KAREN GLANZ: Thank you. Great, thank you so much.
Great presentations.
We have a short time to take some questions and we've had several, so I'm going to try
to at least get through a few of those.
First of all, several of you have talked about food bank and food pantry inventory, and interested
here to hear about anything you have to share on what may be done with respect to culturally
tailored foods for specific communities.
Are there food banks who are working on healthy offerings that are culturally responsive,
or are any of them partnering, for example, with ethnic groceries...grocers to help... support those
who are not consuming traditional Western diets?
Marlene, I don't think we can hear you.
OK.
While you're (CROSSTALK).
DR. GITA RAMPERSAD: I can offer a little feedback from the national level, from Feeding America, if that helps
while she's reconnecting.
You know, I thought this is a great question because it is definitely a focus for us in
health and nutrition at Feeding America's National Office.
We ran a session at one of our annual conferences, the Feed Nourish Connect conference over the
summer, and we featured some of our food banks that are doing just that.
And it's a priority for us in so much as we develop our own nutrition and food banking
toolkit for the network, for our network of food banks.
And you know, and there's a pretty large section devoted to the culturally sensitive delivery
of food and choices, needs and preferences.
So, I see you're back, I'll let you take over.
That was exactly what I was going to say.
Great. Alright. So, a question.
Stepping back a little bit about the food insecurity data.
So maybe Adam Drewnowski, do you might want to speak to this?
You've talked about the spikes in food insecurity and the experiences among different groups.
But the report that came from USDA, a couple of weeks ago showed that the overall rate
was fairly flat, as you noted.
So, what do you make of the gaps in what you've seen on the ground and food insecurity estimates
from Feeding America and what we heard from USDA?
DR. ADAM DREWNOWSKI: Well, let me take this on because I think that when you look at national data
and averages for something as individual as food insecurity, you can get misleading information,
for example, if you have two meals and I have none.
On average, we have one each.
Yes, we do.
So even though the national average may be 10%, the pockets and areas and communities
with food insecurity reaches 40% or even higher, and we need to address that issue.
So, the average on a national level is fine.
But there are communities in need, and I think this is where very fine detailed maps at the
county level, zip code level, even census tract level are invaluable, because they give
food insecurity essentially an address.
You know which neighborhood to go to and where to intervene.
DR. KAREN GLANZ: Great.
Gita, do you want to add anything to that?
DR. GITA RAMPERSAD: Sure, yeah, I echo everything that Adam says that we were also looking at this from surveys
that we were running within our network.
And so...as I spoke to some of our food banks in follow up conversations, even those numbers
weren't reflective of what they were saying, just like Adam was saying.
I mean, we saw one in three in Boston, for instance, people going hungry during 2020.
So yeah, I think it's important to really try to get as close to that person facing
hunger measurement as you can, so that zip code opportunities where, you know, where
we're headed.
DR. ADAM DREWNOWSKI: Yeah, I was actually using the obesity statistics as an example because we've been
able to drill down to the census block level and, again, points to huge social disparities
in area geographic distribution of obesity and diabetes.
And I'm saying food insecurity is absolutely linked to the underlying social structures,
the same exact ones.
You know, it has to do with food spending, diet quality and access to healthy foods,
which are actually more expensive.
The USDA came out with the finding of surprising, that it actually costs more to eat healthier.
This was just in a recent review of the first food bank, but we knew that.
DR. KAREN GLANZ: Great, thank you so much.
So, we heard earlier from Gita that a lot of, and also from Adam, that a lot of food
insecure families are struggling also with diabetes, hypertension, other chronic disease.
So, a question here about whether you think pairing a food pantry offerings with nutrition,
education or other kinds of supports for the consumer behaviors would make a difference?
And in what parts of the country might we see those kinds of interventions?
DR. GITA RAMPERSAD: Definitely, I think we should.
It's hard to say when we will see a difference, but I certainly think it's part of care coordination.
So, I certainly support that.
I think we have work to do in trying to figure out what the balance is, because you cannot
deliver this type of information in a vacuum.
People need to understand just as much about their health as they need to understand about
the food that they are taking in, and also understanding their environment, and what's
available to them.
So, I'm certainly for it, but I think it's again, you know, more of a collective effort
to kind of look at it from a care coordination standpoint.
DR. KAREN GLANZ: Great, and then the question specifically for Caitlin.
Are there other studies that have shown positive impacts of the similar types of interventions
that you've tried?
DR. CAITLIN CASPI: Well, we just heard about the SWAP system, which I actually think would kind of pair
nicely with the SuperShelf approach.
It's kind of not either/or.
You can think of ways that SWAP wallet addresses the actual nutritional quality of food.
It pays less attention to things like aesthetic.
And you could think of ways that you could bolster an intervention like SuperShelf, if
we paid even more attention to some of the, um...dietary guidelines and aligns the intervention
in the same way that SWAP does with those dietary guidelines.
So, while, I can't think of that sort of companion intervention, that has elements of SuperShelf,
that has been effective.
I think that there's opportunities to combine some of the evidence and make for a stronger
intervention.
DR. KAREN GLANZ: Great. And on that note, unfortunately, we have to bring it to a close.
So, thank you for some really rich insights today.
And look forward to these conversations obviously continuing outside of our virtual boxes.
Just a reminder for everybody.
We will now actually move into our first poster session, so hopefully, you had a chance to
begin viewing the posters throughout the workshop.
But if not, this is the designated time to actually view the food and security posters
and also chat with the poster authors.
So, you can visit the poster hall, for poster session one, food insecurity track one, that
starts promptly now.
We have nearly 130 poster submissions on a broad range of topics, so we hope you enjoy
that next stop.
And then after that, we'll return for Session 8 about what has and hasn't worked to address
neighborhood food environments and that will be at 2:20. Thank you.
DR. KAREN GLANZ: Good afternoon.
Welcome back from the break.
I hope as many of you as possible got a chance to attend the poster session network and so
forth.
I’m delighted to introduce this next session.
Previous session was on what has and hasn’t worked in terms of reducing food insecurity.
This session is on what has and hasn’t worked to address neighborhood food environments.
The moderator for this session will be Dr. Eric Rimm from Harvard University.
And so after an introductory talk, he will take over and also moderate the question and
answers.
But first, we’re delighted to have a special talk about CDC funded community-based initiatives
to address a neighborhood food environment.
We’re very excited to have Captain Heidi Blanck of the Center for Disease Control and
Prevention as our presenter.
Heidi’s been a real leader in this area over the years, so I’ll now turn it over
to Heidi.
Thank you.
CAPT. HEIDI BLANCK: Hello.
I’d like to thank the organizers for inviting me here today to talk about CDCs funded community-based
initiatives to support healthy food environments.
In the division of nutrition, physical activity and obesity at the CDC's, we support public
health actions to support nutrition across the lifespan.
This includes work to reduce micronutrient deficiencies, establish healthier food environments,
and to help ensure food and nutrition security across the lifespan.
The majority of our funding goes to support public health actions through recipients at
the state and local level.
I’m going to go through some of our examples.
One of our programs is SPAN, or the State Physical Activity and Nutrition Program that
funds state, health departments and local recipients.
Currently, we fund 16 state health departments in 152 communities.
They implement interventions that support breastfeeding health and nutrition, as well
as physical activity.
Our practitioners work to support state levels, statewide systems changes, and they evaluate
these through specific select strategies as well as performance metrics.
Another one of our programs is the High Obesity Program.
The High Obesity Program funds 15 land grant universities that leverage community extension
services to increase community access to healthier foods and physical activity.
In counties that have 40 percent or more of adults with obesity, residents may have less
access to healthy foods and fewer opportunities, and many of these are in rural areas.
Recipients implement community and anchor institution strategies to increase access
to healthier foods, and there’s an evaluation component for program improvement.
The next program I want to tell you about is our Racial and Ethnic Approaches to Community
Health or REACH program.
The REACH program focuses on improving chronic disease for specific racial and ethnic groups
in urban, rural, and tribal communities that have a high burden of chronic disease.
We currently fund 36 organizations across the country to implement strategies to address
racial and ethnic health disparities with the centering of equity.
And this includes local tailoring of evidence informed interventions to support…support
healthy nutrition, as well as PA, reduced tobacco use and community clinical linkages.
Again, these public health programs have both performance metrics as well as select strategy
evaluations.
To get into detail in some of the nutrition interventions, I’ll start with SPAN.
Within our State Physical Activity Nutrition Program, we work with mostly state health
departments to implement food service guidelines.
Food service guidelines operationalize the dietary guidelines for Americans, and they’re
a way to implement healthy nutrition standards in many of the places we spend our time, such
as hospitals, universities or colleges, private workplaces, as well as state, local and Tribal
government facilities.
There’s a number of community settings, including parks, stadiums and buildings where
organizations meet as well as multiple venues within these places, such as cafeterias, cafes,
grills, snack bars, and really this is to create healthy defaults, so increasing the
supply of healthy foods.
The food service guidelines were first published in 2011.
We then updated them in 2017.
And we currently include four domains, nutrition standards for healthier foods, food safety,
behavioral design that helps with business practices and choice architecture, as well
as sustainability and local product preference.
The HOP and REACH community nutrition strategies are a little bit different.
They include working with food vendors, distributors, and producers to enhance healthier food procurement
and sales.
This could be through cooperative buying, such as through food hubs.
It could be a collective of network of food sales outlets.
It can be tools to match local producers with institutions.
And again, there’s more opportunity for innovative practices that are really community
driven.
In addition, we help them support healthy nutrition standards and key institutions.
Again, this might be in places like hospitals, after school and recreation programs, community
health centers, faith-based organizations, food banks and pantries, as well as in this
area we include early care and education settings.
Thirdly, they can make improvements to state and local programs or systems.
So some of this includes supportive voucher incentive programs, increasing electronic
benefit, tractor acceptance, improving public transportation routes to food stores, and
access to healthier venues.
Here’s an example of some of the healthy incentive programs that are within the REACH
program.
So for example, partners in Health in Navajo Nation in a number of communities, Allegheny,
Pennsylvania, County of San Diego, as well as Marion County.
So for example, in Marion County, Indianapolis, their reach food system strategies include
working on nutrition incentives, the SNAP matching program, for example, that was established
in 2013.
They also work on produce prescriptions.
They have healthy retail initiatives including corner store work, as well as work with small
independent grocers, and then food service guidelines or nutrition standards in healthcare
settings and in food pantries.
I just wanted to show an example.
So we provide training and technical assistance to support food service guidelines.
And in part of our materials, we do include logic models that can be used by both the
evaluators as well as individuals who partner with our programs on more aspects of research.
Folks may be aware that for public health practice, they’re not allowed to conduct
research per se.
It’s really for improving their own program, but they can have a secondary goal of studying
impacts as it relates to more generalized…information.
I’d like to also point out that, because these are often in the business community,
we also have interests by researchers and evaluators to look at business practices as
it relates to job creation, as well as sales.
For folks who’ve looked at the UNC Center for Training and Research Translation, they
also have a number of logic models that are used by evaluators in our public health practice
programs.
For example, this is out of the Los Angeles County Food Service area.
This was assessment of their contracts as it related to outcomes.
And we were able to look at, for example, here, the target populations and whether they
were able to increase consumption of healthier foods and whether this led to greater penetration
of healthy food access within the community.
Here’s one more example of logic models that can be used by evaluators in assessing
both improvements in their program, as well as then more generalized information that
can be published as research.
So this, for example, is a healthy corner store initiative, for example here, looking
at what improvements in the food environments within WIC stores, and then what that meant
for sales to WIC participants.
I just wanted to point out a couple of publications that have come out of recipients.
This included work in three Louisiana parishes.
This included a healthy food demonstrations within stores in-store marketing and encouraging
owners to stock healthier food items.
This example that was published in preventing chronic disease, unfortunately, did not show
an increase in purchasing of healthier foods or a change in healthier diet habits, although
it did find modest changes in the food store environments.
As another example, in the HOP program from rural Kentucky, they were able to work with
both a social marketing campaign that was called Plate it Up Kentucky Proud, as well
as changes within stores themselves and markets.
The bottom of the slide does show here from year one to year two of the program, the mean
number of servings per day of fruit increased significantly from 2.71 to 2.94, and as well
as an increase in servings of vegetables per day.
So there are some examples where public health practitioners are able to publish research
on the work they’re doing in these spaces.
Finally, I wanted to end with some systems change work.
This includes our Building Resiliency in Communities, our BRIC program, again, during COVID, I,
there’s been a large interest in the charitable food system and how we can ensure that individuals
are…being both food secure and decreasing hunger.
This includes quite a bit of work on food councils or coalitions and how food pantries
and food banks are able to take part in the planning efforts, increasing nutrition standards
or guidelines and food banks, ensuring that we’re reaching populations in need, and
then also, again, in bringing in community venues using financial incentive programs.
So, to end the, I’d like to thank you today for your attention.
Just to bring about that CDC’s funding really does try to support addressing social determinants
of health, including food and nutrition security.
Our recipients are involved every day with interventions that we would probably classify
in the research setting as natural experiments.
They’re very much involved in implementation science…principles such as engagement and
their evaluation can go from light to rigorous.
They do have a primary goal of improving their programs, but they can have a secondary goal
of informing the field, creating generalizable knowledge.
And so we do really often suggest where we can to match, make researchers to also become
program evaluators.
This really helps us spread lessons learned using implementation science principles with
an equity lens. Thank you.
DR. ERIC RIMM: Thank you, Heidi. That was great, and thank you, Karen, for the introduction.
I’m glad to help out with facilitating the Q&A for the next panel.
And I’m, I’m really delighted that Heidi has agreed to stick around and be part of
our next Q&A for our panel.
So, if anybody has questions for Heidi, please put them in the Q&A at the bottom.
Next up, we’re going to have us move on to panel six, which is strategies to improve
neighborhood food environments, what…what has and hasn’t worked and why.
This, this panel will…will examine policies, strategies and contextual social factors that
can influence neighborhood food environments.
So I want to welcome everyone to our panel.
It’s…it’s…we’re going to be looking at both actually effective and ineffective
interventions that have been used to address food environment changes that influence dietary
behaviors.
So I’m going to introduce the…the three speakers now, and then we’ll have a Q&A
at the, at the end.
So, remember that if you have questions for any of the three speakers, put them in the
Q&A and specifically address them to which of the speakers you’d like to answer.
So let me first…first up will be Dr. Roland Sturm of the Pardee RAND Graduate School.
He will discuss the outcome of a fast-food ban in Los Angeles.
Our next speaker, Dr. Chelsea Singleton of Tulane University School of Public Health
in Tropical Medicine, whose presentation will focus on evaluating the Healthy Food Financing
Initiative.
And finally, our last speaker, Dr. Allison Karpyn of the University of Delaware, will
discuss healthy in-store marketing practices.
So I, I look forward to, to your talk and I’ll pass it over to Roland.
DR.
ROLAND STURM: My talk is about zoning for health and with a particular focus on the
Los Angeles fast-food ban.
The 2008 fast-food ban is narrower in scope than fast-food ban sounds.
It was a regulation, an ordinance that prohibited remodeling, opening, building new standalone
fast-food restaurants in South LA.
So not all of the city of Los Angeles, but an area of about 700,000 people.
It’s relevant sort of for the history of anti-obesity and diet is, that is the first
zoning regulation that explicitly mentioned it.
So, language included, it’s an over-concentration of fast-food restaurants in South LA and that’s
detrimental to the health of the people of the community.
And this map shows the fast-food ban area.
Black is the LA, Los Angeles County, green is the City of Los Angeles.
The fast-food ban area is the shaded area that is the sort of the South and part of
East Los Angeles.
Let’s step back in time.
Even though the 2008…regulation may have been the first one about diet, obesity, zoning
regulation has been around for much longer.
In fact, 100 years prior to the fast-food ban, LA passed the first citywide zoning into
residential industrial districts.
And it may have been the first one in the US above for city doing the whole area itself.
It followed up piecemeal regulation that has been around where you can bury your dad or
get drunk or keep your cows.
That was clearly about health and quality of life.
And there was some idealism involved.
Nowadays, zoning gets also bad rap with a single-family housing contribution to sprawl
inequities.
And any regulation or the zoning laws, there’s always the risk of captured by interest groups.
This was the 1908 language of...in Los Angeles, I have a facsimile from Bakersfield, when
they adopted the same…regulations.
You can clearly see from the restrictions in residential areas.
This is an environmental health safety aspect.
So now, in residential areas, you could no longer have stone crushers and fireworks factories
and slaughterhouses…laws and regulations are absolutely essential for functioning society.
But they also need to be good laws and regulations.
Any regulation has its costs so we want to make sure it achieves its goal and it’s
not just a burden.
It’s particularly important because regulations can be captured by interest groups that have
their own agenda.
For me, as a researcher, the first question is, do the magnitudes line up?
So does the regulation, in fact, deal with the targeted problem?
My first analysis was just looking at the business patterns to make sure that what was
claimed about the business structure actually is true.
Here was still using data from for U.S.A. later, I used the food inspection data from
the county itself.
Here I calculated densities per 100,000 residents and also per roadway miles.
Fast-food density per capita was actually not that high in South LA before the regulation.
As long as you define fast-food by the big chain, the franchises, the ones that were
target, the prototypical ones, if you look at McDonald’s, Burger King’s, the biggest
names, they were very similar between South LA, West LA, which is a rich area or the county
average.
And if you look at all the franchise chains, they were actually lower in South LA.
Now, the actual business counts.
Were really hard to reconcile with the claims about the over-concentration because we get
two things.
Either the density of fast-food chains are lower and using the per capita measure, which
would be my preferred one.
But if you say per capita is the wrong measure and you have to do per roadway amounts, then
the density of fast-food chain would be similar.
But the real difference in the one we, you would want it to address is there would be
far more small food stores and convenience stores.
And a few years later, of course, I wanted to know what happened after the regulation.
And for that, I got the retail food permit data from the LA County Department of Public
Health.
That is, the data they use for the food inspection.
They are data spreadsheets and to look at which are the new permits that came up in…in…in
the years, distinguishing sort of all the different types of places, including the small
food stores.
So the new food outlets that popped up in the, that was the four years after the…regulation.
Mostly small food stores, very rarely independent, larger restaurants.
And you can see there are differences in the business structure.
So, I really would say there are two key differences here.
The largest group of food, new outlets in South LA are small food stores, just lots
of them.
And elsewhere, they’re larger restaurants, but they’re not part of a big chains.
They’re really no significant other differences.
And during that time period, there were eight new fast-food outlets they belonged that were
not standalone, so they were allowed because it was, the regulation only affected standalone
restaurants.
Also looked at individual level data.
Now, I had really no expectation that this would have anything to do with the fast-food
ban, just because the fast-food ban did not change the build environment in any meaningful
way.
Some size here were kind of small.
It was the California Health Interview survey.
I had 5,000 people in the city, but it was enough really to show significant differences
here.
South LA as expected had higher BMI and high obesity rates than the city or the county.
Significantly higher and more disconcerting, it increased even more.
So disparities widened.
Again, you can’t blame the fast-food ban for it, but nor did the fast-food ban make
any difference.
And looking at food consumption, per se, there are really no difference.
Things go up everywhere or they go down everywhere.
The bright spot is really the decline in soft drinks.
It goes down everywhere.
That really happened nationwide and happened in the early 2000s.
On the other hand, fast-food consumption still at that point was increasing everywhere.
So my summary here would be changes in diet and obesity.
Well, the fast-food ban didn’t do anything.
This was distracting from the, the real problem, the trends that are both positive and negative,
they’re largely the same.
High obesity rates everywhere, more fast-food consumption, reduction in soft drink consumption.
But the…the tread was worse in…in South LA.
VIDEO RECORDING AUDIO: Well, it’s 2021 and I’m in South LA.
In fact, in Watts at the, is the iconic Watts Tower, which is really tiny.
But, strangely enough, Watts is not a fast-food ban area, but the areas around it are.
And so we’ll take a look at those.
DR. ROLAND STURM: I just pulled from Adams onto Crenshaw Boulevard, and that intersection
was in, got lots of pictures because of all the fast-foods there.
There was El Pollo Loco, McDonald’s, a Taco Bell.
Here’s a Subway on the right, a Yoshinoya on the left coming up.
And those have been there since before the fast-food ban.
What has changed, however, is all the places in here that are not part of the regulation.
The King Donut is here.
There’s a little Caesars, there’s American Deli, there’s Mexican place, and those are
new.
And to summarize, the LA ordinance may have been important first, but probably not for
the right reason.
The justification that there were too many large fast-food franchises was really inconsistent
with the business structure doesn’t match up.
Sure, you can find examples, and I just showed you them on the video.
So this was a intersection that got a lot of pictures in the media.
But it’s really not that typical.
Much more typical would’ve been the little turn I did into the strip mall.
There’s really no evidence that the ordinance really achieved change in the business structure,
or a reduction in fast-food consumption or obesity among the residents.
I think type of foods, portion sizes, they’re arguably more important than the type of outlets.
So if you think about a Chipotle freestanding type restaurants, typically very much would
be prohibited by the regulation.
Was the King Donut the first thing you saw when I pulled into the strip mall?
That is allowed, so…that does not really help with diet quality regulations too crude
to tool for this.
There are still value in regulations for the right reasons.
I think for example, the drive-through bans to improve walkability is fine, but if you
say drive-through bans so people eat healthier, that is much harder to swallow.
I have a little coda just now.
Santa Monica Wealthy West Side City created this ordinance that prohibits fast-food restaurants
on the promenade.
Fast-food here is defined as more than 150 outlets nationwide.
And the fear is that there’s so many empty spots right now because of the pandemic that
those will be filled by fast-food chains.
But unlike the fast-food ban in LA that was celebrated in 2008 and then 2010 again, and
in later years, the pushback that people here in Santa Monica is very different.
And here’s sort of the criticism that’s very much what you hear in the council meetings.
DR. CHELSEA SINGLETON: Hello, my name is Chelsea Singleton and I’m an assistant professor
at Tulane University in New Orleans, Louisiana.
And I’m excited to be here today speaking to you at this wonderful virtual workshop
in session eight.
And today I’ll be talking about the Healthy Food Financing Initiative and its impact on
neighborhood food environments in the US as well as Illinois.
I’m presenting on behalf of the Policy Practice and Prevention Research Center at the University
of Illinois Chicago, which is where I completed my postdoc fellowship.
So I have nothing to disclose, however, I would like to acknowledge our funding source.
So, the research I’m going to present towards the end of this presentation was actually
funded by a CDC NOPREN grant.
So I want to acknowledge the NOPREN network.
So let me give you a little bit of background information about the Healthy Food and Financing
Initiative for all event attendees who are unfamiliar with this particular initiative.
So, the USDA estimates about 17.4 percent of US households live in census tracts that
are designated as low income and low access.
Low access, meaning that they have low access to retailers that sell on stock a large supply
of healthy food like supermarkets and grocery stores.
So this particular public health concern is what sparked the…the Obama administration
to create and announce the Healthy Food Financing Initiative in 2010.
It was actually part of the Let’s Move campaign.
So the Healthy Food Financing Initiative has specific set of goals, including to address
inequities and healthy food access, that are impacting underserved communities in the country,
to diversify the retailers that sell food in these communities, and also to engage with
these communities.
And since then, the Healthy Food Financing Initiative has contributed to the expansion
of healthy food retail and underserved communities across the United States in a number of different
ways.
So it has contributed tens of thousands of square footage of healthy food retail space
through a number of different mechanisms and projects.
So some of them being the creation of new stores such as supermarkets and grocery stores.
And then also there has been projects that have supported existing food retailers to
help them expand their supply of healthy food.
So, corner stores, smaller grocery stores, to…to allow them to carry a larger stock
of healthy food.
And I want to acknowledge the Food Trust, the PolicyLink, as well as the Reinvestment
fund because these particular organizations, many of you are familiar with them or are
affiliated with them, have studied the broad impact of the Healthy Food Financing Initiative.
And they have been a great source of information on this initiative since its inception.
And they have published a number of reports on it.
But one of the things I do want to highlight is the economic contributions of the HFFI.
So over 4,000 jobs have been created, and that job creation has led to workforce expansion
as well as local…economy growth and community empowerment in the communities that have received
HFFI support.
So on this particular slide, I quickly summarized some of the research that has been conducted
today.
And much of it has been conducted by presenters and attendees of this virtual event.
But out of all the studies that have been conducted, many of them have been conducted
and in sites where there have been HFFI supported projects and they have looked at outcomes
such as community level impact the changes that retailer availability, density and diversity.
They’ve also looked at store outcomes.
So, looking at the food retailers in communities as well as the, the, the new retailers to
see what if they’re stocking, the prices of food and beverages as well as, you know,
in-store marketing strategies.
And then finally, a…a research has focused on outcomes that have impacted the consumer.
So we’re really interested in knowing how HFFI supported projects have resulted in changes
to consumer behavior such as food and beverage purchasing, their food security status, various
different aspects of dietary intake and even some health outcomes such as obesity.
And overall, a lot of the research is in the community and store space, looking at changes
to the neighborhood food environment.
However, there is a small subset of studies that have…collected consumer information,
although a lot of this research hasn’t found much findings in terms of significant changes
to outcomes such as diet and obesity.
So I’m going to talk a little bit about the HFFI in Illinois, because that’s what
I mostly worked on when I was a postdoc at the University of Illinois and Chicago.
So, like I said, UIC’s Prevention Research Center received a NOPREN grant to actually
study the…the HFFI and its impact on neighborhood food environments in two areas of Illinois
that receives HFFI support.
So the first area being Rockford, Illinois, which is about 90 miles Northwest of Chicago.
And a nonprofit organization called the IFF, the Illinois Facilities Fund actually leveraged
HFFI funds to develop a new supermarket in Rockford.
And then on the South side of Chicago, the community…the Chicago Community Loan Fund
leveraged some HFFI support to open a new supermarket in the Inglewood community on the South side
of Chicago.
So we’re going to talk about those two sites specifically.
So this is some descriptive information about UIC's NOPREN project that I participated in
when I was a…a fellow at UIC.
And I would like to say that all of our research findings have been published already.
So I’m happy to share with you all of the papers that have come out of this project.
From 2015 to 2018, we collected data from four communities, two of them being in Rockford
and two of them being in Chicago.
The Rockford site, they actually received a stabilized supermarket.
It opened in August of 2015.
And on the South side of Chicago and the Inglewood community, they received a Whole Foods Market
and opened in September of 2016.
Both of these communities were predominantly African-American and had a large number of…residents
who were impoverished.
And again, what we were interested in was actually studying how these stores were going
to impact the existing food environment, which primarily comprised of non-chain grocery stores,
corner stores, gas station, liquor stores, pharmacies and discount stores.
So we collected data from the existing stores to see if there was any change in food and
beverage availability and marketing.
So, like I said, all of our papers have been published.
So, if you were really interested in what happened in the Rockford site, I’m happy
to share with you that paper.
Just shoot me an email and I will get that information to you.
But I’m going to focus specifically on what took place on the South side of Chicago and
the Inglewood community.
So, like I said, a Whole Foods Market opened, and this is the Whole Foods Market that opened
in Inglewood Square.
It’s actually now this square is the home of several other retail businesses, some of
them being non-food retail businesses.
And it has led to the development of hundreds of jobs.
Many of these jobs are occupied by people who live in the Inglewood community.
So again, it shows that broader economic impact on this community.
Because of this HFFI supportive market coming into the community.
We recently published our paper with the findings from the Whole Food site, the Inglewood site,
and it’s…is demographically matched community, which is North Lawndale.
So you can see in that paper we summarized changes in food and beverage availability
across this community over the course of two years after the store opened.
So our baseline findings reflect 2016, and then we did two follow up periods, 2017 and
2018.
This is just a snapshot of the paper, so you can actually see fruit and vegetable availability
in the small stores that existed.
And as you can see, on average, these stores were not offering a large variety of fruits
and vegetables at baseline and two and as well as two years post the store opening the
Whole Foods Market opening.
So that was one of the key take home messages that we didn’t see significant changes in
the existing food retail environment.
However, adding this market greatly contributed to the total amount of healthy food retail
space in the Inglewood community.
So looking ahead, I…I quickly want to summarize…as I wrap up my presentation today is that we
have there…we have a lot of knowledge right now about the Healthy Food Financing Initiative.
However, I do believe there are some gaps and some opportunities for the field to really
expand its understanding of the Healthy Food Financing Initiative and its impact on neighborhood
food environments.
So the first thing is that a lot of the projects that have been conducted to date have been
very…in terms of research projects have been very site specific.
So we focus solely on what’s going on in Chicago or what’s going on in Pittsburgh
or what’s going on in New York.
We don’t really have a solid understanding of what’s going on at the national level
in terms of that detail…detailed data at the national level.
So I think that’s an opportunity for some research.
I think it will be great to really understand how the HFFI has impacted inequities by community
characteristics, racial ethnic composition, as well as differences between urban and rural
communities.
I think that will be a great opportunity to expand our understanding of the HFFI.
Finally, we see that the, we see that the HFFI has affected, you know, local, the local
economy, but it’d really be interesting to see how has it impacted social and environmental
issues such as blight, violence, social cohesion, and educational opportunities.
And of course, everybody is studying the COVID 19 pandemic right now.
So I’m really curious to see how the pandemic has affected neighborhood food environments
that have been the sites for HFFI supported retail expansion projects.
And also, I just want to highlight that I think it would be a great opportunity to really
understand the HFFI if we developed a central research hub.
So that means like bringing researchers together who do this research so we can collaborate
and, you know, develop synergy across projects so that we can get a better understanding
of the HFFI and…and pull together our resources and share them to the public.
So I just want to acknowledge all of my former mentors, Dr. Powell, Dr. Zenk, Dr. Angela
Odoms-Young.
I want to acknowledge Yu Li at UIC, as well as Amber, who is the Deputy Director of the
Prevention Research Center.
So, thank you all for listening to my talk today in session eight.
This is my email address.
You can contact me if you want access to any of our papers.
You can also follow me on Twitter @DrCRSingleton. Thank you.
DR. ALLISON KARPYN: Hello, my name is Allison Karpyn and I’d like to thank the NIH workshop
conveners for inviting me to present today on strategies to improve neighborhood food
environments, including a review of what has and hasn’t worked and why, particularly
related to healthy in-store marketing strategies.
I’ll be drawing from a recent review article that was published with my colleagues, Kathleen
McCallops, Henry Wolgast, and Karen Glanz in the International Journal of Environmental
Research and Public Health.
I encourage you to go there if you’re interested in more details on this study.
So we know the foundation of the field is really in the concept of four Ps, product,
placement, price, and promotion.
And it’s the manipulation of these four Ps and different combinations that results
in the basis of a lot of the in-store marketing interventions that we see in public health.
Initially this concept was well described in the document, harnessing the power of supermarkets
to help reverse childhood obesity, which kicked off much of the thinking in this space.
I want to touch on some of the prior reviews.
Going back to 2012, Karen Glanz and colleagues initiated a study to look at the grocery retail
marketing strategies that were employed between 1995 and 2010, and they found 125 studies
and captured that promotion and placement strategies were very common and also saw an
increasing number of multicomponent intervention studies at the time.
There was concern for some over reliance on self-report data and also low response rates,
as well as concern for lack of…diversity in the populations of interest, in particular
among business literature.
There’s also recognition that there was an increasing number of online studies which
had not been transferred to be tested in real life settings.
So some uncertainty about the extent to which some of those online applications would apply
to real life settings in some of the computerized studies.
Another study was published in 2013 looking at some of these same interventions, 33, and
found similar results including concern for the rigor that was reported in the studies
and, and in particular, lack of information about the effect of interventions on customer
purchasing behavior.
The review also pointed out the prominence of point of…purchase information strategies,
including those strategies at the register, which might include anything from couponing
taste testing to recipe card give outs, and also display strategies at the register.
Our goal with the most recent review was to update the state of the literature.
And so we incorporated studies from 2010 to 2019.
We included mixed method studies as well as quantitative data.
And our focus was on researcher or retail or initiated studies that were conducted inside
the retail environment.
So we excluded things that would not have been conducted inside the retail environment.
We focused also exclusively on purchasing and consumption related outcomes.
So if a study didn’t have an outcome that was related to purchase or consumption measures,
it was not included.
All in all, we ended up with 64 studies.
We started off with a large search, ended up excluding many, and then did a backward
search where we found another 22 studies for a total of 64.
If we look now at the…what we see initially, and we’re going to describe here a capture
of the types of studies first, and then we’ll look a little bit more detail at the outcomes
that we saw.
But if we capture the types of studies, the research designs were largely non-experimental.
So while one in three studies were, which is positive, we found that about two thirds
were not.
And in fact many had no control group at all.
We also found that the duration of the average study was relatively short.
Most were less than one year, very few were more than one year.
And even as short as 22 minutes.
We found the settings that were reflected in the studies to be quite broad and honestly
mirrored a lot of what we saw 10 years ago.
So we’re still seeing largely equal representation, perhaps a few more in the supermarket of supermarket
corner store and other grocery store.
And this is defined largely by the number of registers or the size of the store or even
the types of products that the store sells are thriving.
About half of the studies that we looked at when it came to these purchasing related measures
or consumption-related measures focused on objective purchase related data that said
the other half did not, and where they did not, we saw a lot of self-report purchases
or expenditures.
When it came to consumption related measures, again, we see a domination of self-reported
diet or consumption survey type tools and much fewer application overall of consumption
related measures, but then certainly of more rigorous measures.
If we look at trends in the type, the number of components for the interventions, whether
it’s a single component intervention or a multicomponent intervention, we see that
the trend toward both single and multicomponent interventions is increasing.
So there’s an upward trend in the literature, and we don’t see a domination, for example,
multicomponent interventions.
We’re seeing approximate equal usage of both types of study designs or intervention
designs.
So if I start with the good news, because we should all begin with optimism, right?
We do see that 56 of the 64 studies that we reviewed had at least one positive effect.
And that of those that both used an objective measure of sales and a more rigorous method
in their research design, 100 percent found at least one positive effect.
So good news in that front.
We do know though that many 24, as it turns out of our 64 or 38 percent were conducted
without any control or comparison group.
So that’s clearly problematic.
And only 14 of these studies were both experimental and included objective data, which is also
problematic.
If we look at intervention outcomes by single component interventions versus these multicomponent
interventions, we find that predominantly what’s in the field are promotion related
interventions and that they’re generally found to be effective.
So we found at least one positive effect in 27 of the 30 interventions.
We also find that within multicomponent interventions, again, there’s a predominance of positive
results in the literature, in this case, 29 of 34.
Also interesting in this space when it comes to the multicomponent interventions is that
many are multi are manipulating three of the Ps.
So for example, promotion, product and placement, rather than just two of the Ps.
So when they’re doing multicomponent interventions, they’re pretty comprehensive type interventions.
So future directions, we know we need studies that are conducted with control groups.
Rigor has been an issue all along.
And our review in the last 10 years, 24 out of 63 studies had no control or comparison
group.
And some of this concern for rigor two carries over into the outcome measures, whether it
be focused on store sales or other dietary outcomes.
We also are encouraging as a result of this review more thinking around substitution.
So a lot of this data right, is focused on increased in purchasing or increased consumption,
but it’s not really thinking that much about the whole diet.
So how we start to integrate this work into thinking about the whole diet is important,
especially when it comes to substitutions for less healthy foods.
We also think that this body of work begins to ask more questions about sustained effects.
So we found that most of the studies are only looking at data around three months or less
and that there’s very few that go to a year or more.
And when it comes to these kinds of interventions, we know that people tire of recognizing potentially
the intervention and might need more opportunity for turnover, but we don’t know what those
parameters really look like.
We also know that we need to study these strategies in emerging online sales environments.
The movement toward online sales has shifted some purchasing patterns potentially and also
preferences.
So the extent to which these product promotion and placement strategies translate to online
environments is really largely unknown.
While we do have some of those online studies, we haven’t really tested them in this real-world
online environment.
We also know that multicomponent strategies could examine and probably should, the added
effect of each additional component, because as of now, they’re all done….
So that’s my review.
I really appreciate your time and thoughts and look forward to future conversation and
questions.
Thank you.
DR. ERIC RIMM: Welcome back everybody.
Thank you for the fantastic presentations.
That was really fun to walk through and it was a great lead off, Heidi, that you, you
started us with.
So, for, for anybody that wants to add any more questions, we’ve had a bunch of questions
that have come in, but for those people that have some questions for the next 10 or 15
minutes, we can ask each of the presenters.
So let me, let me start out as I pull up the questions.
There was a few questions, Heidi, that were specific to your presentation on, I guess
food service management guidelines that you mentioned.
First of all, do they apply to all food service management companies as, you know, everything
up to Sodexo and Compass down to smaller food service management groups?
CAPT. HEIDI BLANCK: Thanks, Eric.
And just to review that a little bit, so, we have provided food service guidelines and
we work with our recipients, which could be local health departments or community-based
organizations or healthcare organizations.
And with their partners, which often could be that independent food service management
company or one of the large, large groups, they really determine whether that is voluntary,
is it an…or they can incorporate it into a policy.
So it could be within their contracts, it could be within their wellness policy of their
organization.
So these are really meant for that relational, you know…opportunity for within those organizations.
So CDC doesn’t have requirements of these.
They start off as voluntary and then it’s really at that organization level to turn
them into, whether it’s, again, a voluntary opportunity within the food service management
or whether it becomes part of an actual contractual agreement.
DR. ERIC RIMM: Okay, great.
So some of the research that you described, I guess, was where some of the guidelines
were being implemented or was testing how well the…the guidelines were being implemented
as opposed to mandating the guidelines?
CAPT. HEIDI BLANCK: Correct.
We do surveillance actually on policies at both the state and local level.
But that’s a little bit more in the surveillance realm and…less on implementation research.
DR. ERIC RIMM: In, in the areas.
That other question was related, where you do surveillance or monitoring, does that,
is that given feedback or are your results given back to the groups that you were monitored,
that you were monitoring, I guess?
CAPT. HEIDI BLANCK: So CDCs funding, you know, 70 percent of our funding goes out to the
state and local recipients within their grants or cooperative agreements.
They are to set aside about 10 percent of their funding for evaluation.
So that’s how we’re really able to really provide that on the ground information.
It is really mostly done by them, and so they’re really trying to improve for quality improvement.
We do have a number of writing workshops where CDC supports the evaluators as well as organizations
that are…you know, naturally researchers.
So we do have a forthcoming journal supplement and I, I just glanced at it while we were
talking, and it includes Eastern Michigan University, Penn State College of Medicine,
University of Arkansas Medical Sciences.
So you can see that we have in these, were all reach grantees.
So, what’s great about public health practice is that, you know, we’re really pairing
that on-the-ground interventions with folks from the research community.
DR. ERIC RIMM: Great. Thanks.
So, Roland, we, we had a question that came in even though overall you concluded that
the, the, some of the guidelines did not work in LA if you look really carefully, it does
look like SSBs and French fries went down more so in South LA…compared to other neighborhoods.
Maybe that’s just sort of a, there’s a targeted benefit, as you noted, you know,
donuts don’t go down because they weren’t part of the targeted intervention, but is
it possible that the guidelines were somewhat positive for individual foods that we’d
like to limit consumption of?
DR. ROLAND STURM: I see no evidence for that.
And, in fact, I would disagree with you if we look closely and closely means you have
to take into account the quality of the data.
What a big effect, what a small effect, what can you say with precision?
I would say that I see nothing in there.
The fast-food is going up everywhere.
Sodas is going down and, you know, if you try to split things finally and…P-hacking
aggressively just get nonsense.
DR. ERIC RIMM: Yeah.
DR. ROLAND STURM: And that’s very common in, in the diet area really, because people are
looking for something and, but then get carried away and don’t take into account what do
we know what’s better and lower reliability.
So I would say no…no to that.
DR. ERIC RIMM: Okay.
DR. ROLAND STURM: Now, here’s another thing that we don’t really measure, and that is
probably a little bit related to your question.
Does the health food ban create a signal something that changes the social norms around it?
Because all now health food that I think is important and the interaction then between
social norms and what will be offered that will play out slowly over time.
We, we definitely saw that with cigarette taxes, right?
It was not just—
DR. ERIC RIMM: Right.
DR. ROLAND STURM: Cigarette tax change smoking, it was when you visited somebody, it was no
longer an acceptable norm that they offer you cigarette.
DR. ERIC RIMM: Right. So it may be something that—
DR. ROLAND STURM: [inaudible] the intersection between demand and supply is important, and
so the social…social norms play a role there too.
DR. ERIC RIMM: Yep. Great. Thank you.
Chelsea, we had a few questions for you.
You kind of gave us a teaser saying you have published two papers and you gave us the results
for the Whole Foods and not for the Save A Lot.
And both, both questions were, well, one question was in, in Whole Foods, there’s not a, a
tremendous amount of in-store marketing for unhealthy foods and that most of the foods
that are in Whole Foods are healthy.
And so you’re bringing fresh fruits and vegetables to a, to a neighborhood that maybe
had less before.
But can you sort of speak to the Save A Lot where they may have had a lot more fresh fruits
and vegetables, but probably also had a lot more in-store marketing for sugar sweetened
beverages or for other…unhealthy foods?
DR. CHELSEA SINGLETON: Yeah, I can talk about that.
Yeah, so…and so just to clarify, the goal of the project was to really look at changes
to the existing food environment.
So a lot of our focus was on the stores that were in the community before the store, the,
the supermarket opened, so that’s the Save A Lot and the Whole Foods.
But we did collect data from the Save A Lot and we collect data from the Whole Foods.
And the…the Save A Lot was…the Save A Lot did have marketing, like, they were marketing
in store, you know, more unhealthier items like, you know, salty snacks, candy, sugar-sweetened
beverages.
We did see that.
However, our findings were very similar when we actually looked at the existing stores
in the community.
We didn’t see significant changes to what other stores, the small food stores were stocking
and carrying and, and advertising in Rockford as well.
The original health hypothesis was that, you know, this supermarket was going to come in
and maybe these stores were going to adapt somehow, maybe for the better, maybe for the
worse.
Maybe they were going to try to stock and advertise more healthier items, or maybe they
were going to pull back and stock focus on the unhealthier items.
However, we didn’t see significant changes and, you know, we actually been thinking,
you know, thinking deeply about that.
And I know there’s been some qualitative work really around, you know, really understanding
small food stores and the relationship that they have with communities.
And, you know, we didn’t see significant changes to their business.
We didn’t see like the number of store, we didn’t see store closings as well.
So, yeah, I mean, adding these stores to the community of course contributed to the expansion
of the retail space because the store wasn’t there before then.
However, we didn’t see significant changes to the retail food environment in either community.
DR. ERIC RIMM: Okay, thanks.
So it didn’t, it didn’t change the overall demand for fruits and vegetables across the
community such that it, you know, one store didn’t raise up the entire neighborhood
or sink the entire neighborhood, but as you noted, it brought a lot more employment to
the neighborhood, so that was a sort of indirect benefit.
So that’s great.
DR. CHELSEA SINGLETON: Yeah.
DR. ERIC RIMM: So, Allison, there’s a, a few questions for you. Let’s see.
So one, one of the question is what is the sort of the status of examining the role of
the food environment beyond the, beyond the actual food store and the neighborhood?
Meaning what about the food environment of an individual’s work commute or examining
if people do actually stop within their neighborhood?
Or is it…are we concerned about beyond the neighborhood?
DR. ALLISON KARPYN: I’m not sure if this is, yeah, really a question for me, given the
presentation that I’ve been giving, but I do happen to understand a bit about this,
given some of the research that I’ve been doing.
But I think that we do know that the food environment, the studies of the food environment
and where you shop for food, whether it be on and on your commute, which is a very common
place of shopping for food, at least before COVID, and where your primary store is, is
a major point of research interest,
especially when it comes to the HFFI funded stores, whether or not people are shopping
at them has been a major area of interest.
I think Tamara Dubowitz’s work and others has really pointed out that this is a major
factor.
I don’t know if that answers the question entirely, but…
DR. ERIC RIMM: Yeah, no, I think that’s, I mean, I think that speaks to the question.
So, Allison, are there, can you, are there specific policy implications that you have
in mind?
You summarize the area there; you found some good and bad things that are going on in the store.
Can…is the, is this leading to something where you’d, like, is there’s a specific
policy, whether it be FDA or USDA that could come out of this, that could benefit the food
environment when you’re in the store?
DR. ALLISON KARPYN: Yeah, I think there’s a couple of opportunities that could be, could
be pursued.
I also recently published a article on WIC vendor criteria.
And I think there might be an opportunity to look more critically at what we’ve learned
from the in-store marketing literature and what we know is possible from WIC vendor criteria
perspectives.
We know there’s a lot of variation across the country.
We know there’s opportunities when it comes to labeling, for example, shelf labeling for WIC.
And maybe there’s a way for us to…to merge some of our learnings across both of those fronts.
So I see that as one of the…obviously it’s…it’s not an easy approach, but I think it’s one
that seems very possible in…in a reasonable period of time to start to think about how
to integrate.
DR. ERIC RIMM: Yeah.
So do you mean to like extend that to SNAP?
There’s sort of what’s, what’s working for WIC try to make SNAP eligible scores also?
DR. ALLISON KARPYN: Yeah, I think WIC might be the easiest first step, but SNAP is certainly
another possibility I think because the literature tends to target a better for you product and
WIC tends to target better for you products.
There’s a little bit potentially more of a synergy there, but it doesn’t mean that
if we got some great minds together, we couldn’t think about how to apply it to SNAP too.
DR. ERIC RIMM: Yeah.
Well, we have four great minds on this (laughs), four great minds right here.
Let’s see…Heidi, do you have any, any thoughts on, on that sort of the, the surveillance
of the marketing aspects of what’s going on?
CAPT. HEIDI BLANCK: Well, I was actually just thinking about the other component that Allison
was bringing up.
You know, CDC, we’ve been working one of them with one of the major dollar format stores
around their healthier brand selection.
They have moved to have an in-store or…or a dietician for their headquarters that’s
reviewing their, their healthier brands to reduce added sugars, sodium add, and more fiber.
But they’re not currently a major WIC retailer.
And that has to do with their distribution chain because right now we have 50 state models
of what’s accepted on WIC.
DR. ERIC RIMM: Right.
CAPT. HEIDI BLANCK: And so Tennessee may say it has to be a 12-ounce jar of Jiffy peanut
butter and Kentucky might say that it’s got to be a 10-ounce jar of creamy peanut
butter, and Georgia may say it’s a 16 ounce.
And so that’s very difficult for interstate commerce for the trucks that are running across
our nation with supplies to be able to ensure that each…each store is going to get what
it needs.
And so I think there’s a lot of discussion that could happen about creating maybe a core
package that’s maybe a 70 percent healthy foods of what’s in the WIC package, tuna,
brown rice, peanut butter, soy yogurt that maybe independent grocers could meet, or small
mom and pops could also meet.
Right now, you have to be a very large vendor to be able to really negotiate and have an
efficiency in stocking those WIC standards.
DR. ERIC RIMM: Yeah, that is a challenge.
That’s why I was kind of nudging towards making it SNAP because SNAP is nationwide
even though there’s, you know, very few guidelines, but we could somehow merge the
what’s offered on SNAP with what’s what, how you’re allowed to offer it in the store
such that…that the healthy foods somehow are, are pushed forward and the less healthy
foods are pulled back as sort of part of being a SNAP eligible store, so.
Okay. Well, thank you all.
That was really a interesting discussion and, and the reality does set in that there are,
there are some things that work and some things, as Roland said, may take several decades to
work, like the cigarette taxes and, and maybe fast-food bans, well, don’t work right
away, but some, some aspect of changing the, the social setting may, may take a long time
to, to change.
So, okay.
So, thank you all for, for the questions and for the, the session.
We’re going to take a…a moment for a break now between 3:20 and 3:35.
You can come back to the networking lounge and…and hang out and talk to some of your
colleagues.
And then at 3:35 to 5:55, we’re going to go to poster session two.
I…I’ve taken a peek.
We have over 50 posters ranging from intervention research to case studies and qualitative research.
So I urge you to take a look at the poster session for 20 minutes and then we’ll come
back for session nine, the cross-sectoral partnerships to address food insecurity and neighborhood
food environments that will start at 3:55.
So thank you. Thank you again.
DR. ANGELA ODOMS-YOUNG: Welcome back.
I hope you enjoyed the Neighborhood Food Environment poster session.
We're moving into session nine Cross-Sectoral Partnerships to Address Food Insecurity and
Neighborhood Food Environments.
Our next panel will examine the best practices in bridging gaps among various settings when
developing effective interventions to reduce nutrition related disparities and promote
health equity.
We have Dr. Diane Harris from the Centers for Disease Control and Prevention who will
serve as our moderator for session nine.
And so, I'm going to turn it over to you, Diane.
Thanks so much.
DR. DIANE HARRIS: Thank you, Angela.
And welcome everyone to our final panel of the workshop.
Our panelists will highlight exemplars that focus on the importance of community engagement,
community-based participatory research and health care partnerships that tackle food
insecurity and poor neighborhood food environments.
First, Dr. Antwi Akom of San Francisco State University and University of California, San
Francisco will speak on community engagement perspectives and the use of technology to
address health disparities.
The next speaker will be Dr. Jennifer Obadia from Project Bread.
She will discuss emergency food systems and the health care partnerships that they have
at Project Bread to address hunger and food security.
In the session, we will have Dr. Tiffany Gary-Webb, University of Pittsburgh to talk on the REACH
Program and the Diabetes Prevention Program, two programs that are funded by CDC targeted
to at risk communities.
Roll it.
DR. ANTWI AKOM: Hi, my name is Antwi Akom and I am a distinguished professor and founding
director of the first and only joint research lab between UCSF and the medical school in
San Francisco State University and the only college of ethnic studies in the United States.
And it's called the SOUL Lab, the Social Innovation and Universal Opportunity Lab.
Today, I'd like to talk to you about how participatory technology and community driven data is transforming
poor food environments and advancing health equity with our nation's most vulnerable populations.
In particular, I'd like to focus on some of the work we are doing and have been doing
around the country, building local data capacity, increasing access to healthier foods, physical
activity centering community voice, building power and self-determination, building the
evidence-base around racial and spatial data, racial and spatial justice.
Making data equitable, actionable, shareable to drive systems change, developing effective
community-powered interventions to reduce nutrition health disparities.
And all of this not from the top down, but from the ground up.
These are some of the key session objectives which you can view at your own discretion.
A little bit about who we are.
Over the last five years, the SOUL lab, which I have just introduced you to has developed
a platform at a process called Streetwyze.
And Streetwyze is a power building and participatory technology, mobile mapping and SMS platform
that gives everyday people, residents, community- based organizations, health care providers,
a complete picture of what makes us healthy and unhealthy in our communities.
We have partnered with CBOs, with block clubs, with food banks, with food pantries, with
public health departments, with community clinics, with whole health care systems.
And we in Streetwyze believe the people closest to the problem are the people closest to the
solution and that everyday people are experts in their own communities.
If you haven't heard about Streetwyze way, way, way back in the day, it seems like a
long time ago, in 2016, President Obama did invite myself as well as the co-founder Aekta
Shah to the Frontiers Conference which brought together the world's top innovators to present
our work.
And subsequently, we were invited into the White House Opportunity Project.
So, on the right hand side is a picture of myself at the White House all dressed up as
you can see, standing next to the former Chief Data Scientist DJ Patil.
There's Aekta, the co-founder of Streetwyze and a community member and in the bottom right
hand corner is a handwritten note from DJ Patil thanking Streetwyze for everything we're
doing to make cities work for 100% of the people.
Subsequently, there's been press about Streetwyze in the Atlantic City Lab has written about
Streetwyze as one of the top 12 data tools to help vulnerable populations climb the economic ladder.
PolicyLink has written about Streetwyze as one of the top ten health equity in action
design tools.
The Root has an article about Streetwyze helping to transform so-called food swamps or food
desert into food oases or food 'oasi' and Green Biz has an article about Streetwyze as being
one of the few platforms that can measure different forms of resiliency with community,
social resiliency, culture resiliency, climate resiliency and built-environment resiliency.
The big idea here is we've found a way to integrate community-driven data with big data
and predictive analytics so we can move upstream solutions to food justice as well as the social
and structural determinants of health.
We believe our work can help you all and the many people watching this webinar move from
good to great, or if you're already great from great to greater by providing community-driven,
community-powered, community-owned, real-time data and location-based data, and building
local data capacity for community powered health interventions.
The bigger idea is nothing about us without us.
Everything for us, by us.
How can we make sure that we center community voice?
And this is so important because we are facing a data invisibility gap.
We know the secondary data doesn't tell the whole story.
And we know that low-income communities and communities of color have direct relevant
experience that is otherwise not accessible to public bureaucracies about food justice,
about health equity, and that this lack of information is a major barrier to building
policies and practices that improve nutrition, prevent obesity and advance health equity.
So Streetwyze fills these missing data gaps happening on the ground or at the street level.
We believe the missing link.
If we want more equitable food systems, if we want more community-powered health interventions,
is something that we call tech-equity which is this integration of community powered health
informatics, which give us real-time data, location-based data, data visualization in
a hyperlocal data.
And our methodology and way of doing that is something that we call People Power Placemaking,
which is real-time, two-way communication with everyday people so they can participate
in the design solutions that meet their local needs.
In terms of imagining how Streetwyze works, imagine getting this 360-degree view of what's
happening from the ground up beneath regulatory data sets.
For example, if we're talking about how walkable is my neighborhood, we might use something
called Walk Score.
We know Walk Score well because they are owned by Redfin and Redfin was part of the White
House cohort that I mentioned to you earlier.
Walk Scores, it's a great tool, but Walk Score doesn't differentiate between different kinds
of amenities like liquor stores and corner stores.
So, you could be living in a so-called food swamp or a food desert and have a high Walk Score.
Imagine Streetwyze giving you this 360-degree view of the social and structural determinants
of health.
Whether we're talking about public transit, how safe is the street?
Where can I buy fresh, affordable, healthy food?
What are the real issues in my community that people care about?
And here's an example of Streetwyze in action.
What you're looking at it right now, is a public data set from the Alameda County Department
of Public Health, where the so-called purple dots, where the purple dots represent the
so-called number of grocery stores in East Oakland.
This is what the mayor sees, this is what the Alameda County Food Bank sees.
This is what the everyday community member who just wants to know how many grocery stores
in their neighborhood sees.
And as you can see, from all of those purple dots, it looks like East Oakland is a veritable
food oasis.
But when you ground truth that information with the Streetwyze platform and process,
what you realize is that those are not grocery stores.
In fact, most of them are liquor stores and corner stores, and only a handful of them
are grocery stores.
And the powerful thing about Streetwyze is you can upload pictures, audio, video, you
can integrate with social media, which it's a multilingual platform for those hard and
harder to reach populations or for those monolingual speaking populations which are often disproportionately
impacted by the inability to access fresh and healthy food.
So right now, we just want to play a quick video of Streetwyze in action.
This is the 1.0 version.
Imagine we're like an iPhone so we're on like Streetwyze ten right now, but this is a young
lady narrating the food environment in her neighborhood.
(VIDEO PLAYING)
SPEAKER: OK, so what are you looking at? How was it when you went inside? It was dirty when I went inside, and I would never eat anything in there.
Do you consider this to be a grocery store? Hell no. Why? Because they don't sell any groceries, and it's just a bunch of junk food in there.
And I mean, they have little sandwiches, but I would never eat that because it's dirty.
And then all the fruit, it's all like wrinkly and looks old.
And then all the like meat that they did have like the bacon and all that and the little
thing looks like it's been sitting in there for about a year or something like that.
I wouldn't call it a grocery store at all.
So, hell no I wouldn't eat there.
(VIDEO STOPPED PLAYING)
DR. ANTWI AKOM: So, even in this 1.0 version of our platform and again right now we're the
version ten, you can get a sense of what the neighborhood food environment is like even
if you have never been to East Oakland from the perspective of community members.
And because of this kind of data, we were able to put terms of policy wins and programmatic wins.
We were able to put a farmers’ market at the store that previously had never existed.
We were able to go to each of those liquor stores and corner stores.
We were able to go and do retail audits and neighborhood audits and repopulate and repackage
the food environment in terms of access to fresh, affordable, culturally appropriate
food that were offered in the stores with Our Fresh Fund.
And then we were able to use this data with measured JJ to help pass a multimillion-dollar
food commissary.
In terms of other quick success and partnerships, we partnered with the Alameda County Food
Bank, providing real time data on what's working and not working in terms of the food and health
infrastructure in Alameda during COVID.
We've worked with the state of California CalFRESH in terms of the ease of finding culturally
appropriate, healthy, affordable food in low-income communities and communities of color.
We've worked and partnered with the Kresge Foundation which was the first national funder
to intentionally fund and integrate food, art and community driven data to drive neighborhood
revitalization at scale.
We've collaborated with some of my colleagues at UCSF with the EatSF program to map affordable,
healthy food, the healthy food landscape.
And we realized that food is a much bigger issue.
It intersects with other social [inaudible] with folks like Enterprise Community Partners,
the largest nonprofit affordable housing provider in the United States.
They launched an opportunity index on housing, powered in part by Streetwyze.
So, we help them build, provide real-time data on housing, build an evidence-based assessment
framework, make it open source and make it community engagement partnership toolkit.
And we've mapped the geography of homelessness with some of my other colleagues.
And what we've learned is to really have effective, community powered, JEDI driven solutions,
just, equitable, diverse and inclusive.
You have to ask the right questions, whose data is it?
Who owns it? What purpose does it serve? Whose data counts? Who is missing?
Who has decision-making power?
We've also learned that's so important to acknowledge community needs to acknowledge
community strengths to always ensure and center community voice.
And finally, if we really want to increase community data capacity, then we have to increase the
community's capacity through general supports rather than programmatic grants only.
We have to increase training on data science and digital storytelling on participatory
technology, on social media.
We have to implement culturally and community responsive technologies and methodologies,
we have to increase with communities, their capacity to build power and self-determination.
And we have to increase awareness of structural racism and other systemic issues.
And when we do these things, we will achieve food justice and health equity.
We hope that you join us at Streetwyze and the SOUL Lab in building a new community-driven,
community-powered, community-owned data sharing revolution that integrates the power of local
knowledge with official knowledge that helps makes communities and food systems more transparent,
open, connected, smart, shareable, sustainable and equitable for all.
If you want to contact us, please contact us at the emails below or give us a shout out
at Streetwyze.
Thank you so much and we look forward to hearing from you and building with you.
DR.
JENNIFER OBADIA: Hello, my name is Jen Obadia, and I'm the senior director of health care
partnerships at Project Bread.
Thank you to the organizers for inviting me to participate in this conversation.
I'm happy to be here today and I'll be sharing with you our experience participating in the
Flexible Services Program in Massachusetts.
Project Bread for those who are unfamiliar with us is a statewide anti-hunger organization
in Massachusetts, and we work both directly on the ground, providing direct services,
as well as advocating for systems change to address the root causes of hunger.
The flexible services program is enabled through a five-year waiver that MassHealth, our state
Medicaid agency received from CMS.
And there are many components of this waiver.
It's really a step towards a more value-based payment system.
But as part of that, MassHealth members are required to be screened annually for different
social determinants of health.
And members who are food insecure, homeless or at risk of homelessness in conjunction
with having a behavioral or physical health need may be eligible for this flexible services
program.
And really, the idea behind this program is to get at some of those root issues, get out
some of the social determinants that are underlying reasons why different individuals might be
having worse health outcomes or not able to follow their doctor's orders, take their medication,
etc.
So, Project Bread Program focuses specifically on food security and nutrition support services.
And the way that our program works is we receive referrals from any of our three different
accountable care organization partners and at the time of referral the individuals have
already been screened and been confirmed for program eligibility.
And then we call and do an initial assessment.
The point of that initial assessment is really to have a conversation to understand what
the specific barriers are that that individual is facing to accessing healthy food.
And then we're able to provide a variety of different goods and services based on the
barriers that they're experiencing.
So, we can provide grocery store gift cards, we can purchase kitchen supplies and even
appliances like refrigerator.
We offer transportation support, so help getting back and forth from a grocery store.
And then we also do virtual cooking classes as well as nutrition counseling.
We do have three dietitians on our team who are able to offer that one-on-one support.
Finally, we're aware of the fact that our program is not long term, depending on which
accountable care organizations we're partnered with, it's anywhere from six to nine months
in duration.
So, we also always try to work with our clients to make sure that they are participating in
federal nutrition assistance programs so that they continue to have support, even once our
programs ends.
And then finally, we do follow up calls with each individual every three months just to
touch base, make sure they're receiving their goods and services, but then also to see if
there are any changes to their situation, any changes to their diagnosis, to their employment,
to their living conditions so that we can adjust the goods and services that they receive
accordingly.
Our program's been in operation for a little over a year now, about actually almost a year
and a half at this point.
And we are starting to see some early trends that are moving in the right direction.
So, we are seeing positive food security and diet quality improvement, we are seeing that
healthcare is really a critical access point for addressing food security.
And then, of course, really being able to dive deeper into what the components are of
food security that are necessary to address recognizing that it's so much more than just
food itself.
So, all of the clients sent to us are referred to using the Hunger Vital Signs which is a
two questions screener.
At the time of referral everyone answered at least sometimes or often, to the question
about whether or not they worry their food would run out and that they wouldn't have
sufficient resources to get more.
And you can see here that by six months into the program, 25% of our program participants
never worried about whether their food would run out and that we were seeing a shift away
from folks who are often worried towards most being only sometimes worried.
In terms of diet quality, we ask about fruit and vegetable consumption each time we speak
with our clients, and we can see that there's been an increase from the time of the initial
assessment to six months of almost a full serving per day, half of serving increase
in fruits and four tenths of a serving per day increase in vegetables which is a really
significant increase.
And then we also ask our clients about the number of weeks they have access to the foods
that they feel are important for a healthy diet.
And this is a question that was validated through Feeding America's diabetes study.
And at the time of the assessment, only 21% of our clients felt that they could access
healthy foods for more than half a month, so for three or four weeks.
And by six months, we've seen that jump to 53% of the clients being able to access healthy
foods for three or four months...
three or four weeks out of the month.
So, we're really excited to see things moving in the right direction.
You know, we also are seeing that health care is a really critical access point.
SNAP is one of the most important programs in terms of serving as a safety net for those
who are food insecure.
And even though the vast majority of the clients who are referred to us are eligible, only
58% were participating in the program at the time of that referral.
And so, we're excited that by six months into the program, we were able to increase that
to 72% of all of our clients participating in SNAP.
And this is work we would not have been able to do people, we would not have been able
to connect with these resources if it weren't for the relationship that we've developed
with health care through this program.
And then finally, of course, we're coming to understand just how many layers there are
to food security and that it is about so much more than just food.
And so over just the first six months of 2021, we saw 40 clients in need of a refrigerator,
two thirds of our clients needed something needed basic kitchen supplies.
So, cups, bowls, plates, things along those lines, 10% needed transportation assistance
and 38% had very low confidence or had low confidence in their nutrition knowledge and
weren't really sure what they should be eating or how to go about preparing those foods.
So, this just really reinforces for us that it's critical to be offering a variety of
services and not looking only at how to get food into the household.
In terms of next steps, there are some critical, both policy and programmatic changes that
we think are important.
From a policy perspective, we are really excited to see that MassHealth is interested in expanding
support for nutrition support services to the household level is currently were only
able to provide support to the individual whose insurance it is that makes them eligible
for the program.
We also are looking to the state to help us develop a set of shared metrics so that we
can gather data and compare across all nutrition programs to really begin to understand what
types of services and what type of programming is most impactful for which types of patients.
And then finally, at the state level, we're really interested in seeing MassHealth make participation
in flexible services, a requirement for all of our accountable care organizations in the
state and not just optional.
And then in terms of programmatic changes, we are really continuing to dive deep into
research.
We'll be conducting focus groups and interviews in the next year to really start to better
identify what we're overlooking at this point, how to best modify our programming to meet
the needs of the clients that we're working with.
And then we're really looking to focus on components of the program that will have a
longer-term impact.
So, components that will outlive the duration of the program itself because we know, of
course, that the resource, the financial resources that we provide to purchase food will be utilized
during the program itself.
So we want to make sure that we're able to have a more enduring impact.
That is all I have prepared for you today, so thank you so much for your time.
And I look forward to our conversation.
DR. TIFFANY GARY-WEBB: Good afternoon, my name is Tiffany Gary-Webb, I'm associate professor
of Epidemiology at the Graduate School of Public Health at the University of Pittsburgh
and also the associate dean for Diversity, Equity and Inclusion.
And today, I'd like to talk to you about the REACH program, the Racial and Ethnic Approaches
to Community Health Program in Allegheny County which is the Pittsburgh, Pennsylvania area
and vicinity.
In our area, similar to other areas and nationally, we do have racial disparities in many different
outcomes, including chronic disease outcomes.
This is a study that my team did looking at disparities over time in our county.
And as you can see, some disparities have improved over time.
But if you look at the diabetes and hypertension that are highlighted in the red boxes, you'll
see that at 2009 and 2015, there are still black-white disparities in the both diabetes
and hypertension, with black residents having higher rates.
So, given the disparities that we see in our region and some of the health equity work
and partnerships that we've been developing over the years, we embarked on this strategic
partnership from the REACH program.
This is funded by the Centers for Disease Control and Prevention.
It's a five-year grant.
We're working in six priority communities that are predominantly African American, working
in three strategies that I'll talk a little bit more about later, nutrition, physical
activity and linking community to clinical care.
We have 11 contracted partners working on the project, but we have granted many grants
to 20, more than 20 community ambassadors which are grassroot organizations working
in the neighborhoods.
So, our REACH goals are to build community engagement, we want to do relationship building,
active listening, responding to community needs.
Our partners are promoting healthy behaviors, so healthy eating, fitness and routine screenings,
and we're connecting residents to resources.
So, community resources and community organizations and our partners coming together to really
provide tangible resources within these communities.
So, here's a map and a table depicting our priority communities per CDC requirements.
We had to choose census tracts that had at least 20% of the population below the 100%
federal poverty threshold and a high African American poverty rate.
So, these are our priority neighborhoods.
And as you can see, many of them are in the center of Allegheny County which is a city
of Pittsburgh.
But we also have several communities outside of the city, particularly communities within
the Monongahela River Valley.
But as you can see, most of the communities are predominantly African American, and there's
a high African American to white poverty ratio within the communities.
When you compare the REACH communities average to the county as a whole, the REACH communities
have significantly more chronic diseases, particularly heart disease, diabetes, high
blood pressure and more unhealthy behaviors.
Just for our REACH communities, we can see that many of them have high rates of food
insecurity as well.
So, this is a graph of our team and we, for outward facing things, we are the live well
Alleghany square, we're lifting wellness in African American and black populations in
Allegheny County.
As I mentioned, the primary guarantee is the Allegheny County Health Department.
My team at the University of Pittsburgh is the evaluation team and we are working with
the coalition to plan for a healthier Allegheny that brings together partners across the county
to work on a number of different issues, but they have a chronic disease working group
that helped us to form the organizations within the District three strategies.
I mentioned that we had a community fund that was matched by the Highmark Foundation that
allowed us to give the many grants to our community ambassadors.
And we also have a specific funds for comprehensive community communication strategies to get
the messages out to communities.
This is our kickoff meeting, all of our partners, along with our CDC project officer.
Our nutrition strategies are broad.
So we have nutrition standards where our Children's Hospital of Pittsburgh is working on health
and nutrition guidelines mostly and healthy out of school time, sites and healthy early
childhood sites.
Our food systems strategy is what I'll highlight today.
Our Pittsburgh Food Policy Council is working with our school district to change procurement,
so that's a longer-term strategy.
But organizations just harvest, and the food trucks are trying to increase the promotion
and availability of healthy food options using SNAP and food bucks all over the city, but
particularly at farmer's markets and corner stores.
And we do have a breastfeeding strategy where we have the Pittsburgh Black Breastfeeding
Circle working with African American mothers in the communities and also training peer
lactation counselors to do circles in other communities.
Our physical activity strategy is related to the built environment.
So, we are working on community design variables and our community clinical linkages strategy
links communities to clinical care and screening for chronic disease prevention, diabetes prevention
and so forth.
OK, and I mentioned our community ambassadors, these are just a list of some of the organizations
that are working on the ground in various communities.
They are the grants are to partner with our contracted partners.
These organizations may be neighborhood level organizations that work on economic development
or working on physical activity or working in schools.
But collectively, they are the supporting the work of the partners.
My team is using a community-based evaluation, comprehensive, community-based evaluation.
We're using data from all kinds of sources, from our community surveys and so forth to
really do asset mapping and needs assessment in the beginning.
We are doing qualitative interviews with our partners, with our residents, with the stakeholders.
We are submitting CDC performance measures yearly to the CDC so that they can combine
those metrics with the other REACH projects across the country and can really identify
the collective impact of REACH as a whole.
Right now, I believe there are 36 different partners across the country.
So, we've mapped out our strategies and our partners to the performance measures.
And so, CDC is very specific.
We have sub-strategies under the food systems and so I'm talking about the sub-strategy
where just harvests and the food trust are really working in food markets, excuse me,
farmers markets, corner stores, in the community trying to increase the use of SNAP and EBT
at the farmers markets, giving out community food box that can be redeemed either at farmer's
markets or certain corner stores.
And even thinking about the mix of products within the farmer’s market.
So how many of the vendors are selling produce or selling healthy options?
And so, this is a just a summary of what we found in year one.
In year one, we were able to provide nine new or enhanced places for this strategy,
two new farmer's markets within the priority communities two food bucks or, excuse me,
seven enhanced food bucks distribution sites, four farmers' markets and three mobile markets.
And this potentially impacted 31,366 people.
For year two, we've also measured these performance measures, so for years one and two, we were
able to impact over 46,000 people in ten locations.
And for year two, we were able to increase our food box distribution by over 200%.
And this was due to COVID, the need really became increased during COVID in some sense.
So, some of our partners pivoted to doing food distributions.
So, from year one to two, we were able to increase those sites and we hope by year five
of this project that we will have in site, excuse me, and farmer's markets within all
of these communities.
And so finally, I mentioned that we have a communications firm, a black-owned communications
firm that gets messages out for us.
This is just a summary of our project that goes out publicly.
This firm also helps us with social media messages and success stories.
Here are just a few of our success stories from the Food Systems Strategy.
These are pictures of people out at farmers markets, a mom using her EBT card to buy a
produce set at markets.
And this is a success story that we put out this year that's based on the work of all
of our community partners.
And so, as I mentioned, many of them had to pivot to food distributions and things because
of COVID.
But in the past year, we've had eight mini-grant organizations working with us, impacting over
2,000 participants and giving over 500 weekly meals, or produce boxes and 12 physical activity
opportunities per week.
And so, we are really encouraged by this work.
We did have to pivot for COVID and a lot of our partners have now gone to helping us with
vaccine COVID and flu vaccine distributions and so forth.
But we are getting back to some of our community design work and some of the work that we had
planned pre-COVID.
So, I'd like to acknowledge the leadership team of the REACH project, and I thank you
for your attention.
Thank you very much.
DR. DIANE HARRIS: Thank you to all the presenters.
What amazing presentations, so engaging and so interesting.
Thank you again for sharing your work.
So, we have a number of questions in the chat box and you can continue to add your questions,
but we're going to dive right into those that are here now.
So, Dr. Akom, nothing about us, everything for us or by us.
The question is Streetwyze as an impressive example of community-based dissemination research
at the local level.
Can you speak about how these interventions have shown some early benefits to improve
community behaviors and health outcomes?
DR. ANTWI AKOM: Yeah, I think in the last presentation, which was also fantastic, thank you for that,
as was the presentation before that.
I think there were a bunch of examples about how platforms and processes that are community-centered,
community-based can really improve our key performance metrics from a position of making
them more just, equitable, inclusive and diverse.
For us, we've been able to do things like increase 30% ease finding in terms of finding
culturally appropriate and healthy food.
We partnered with the Alameda County Food Bank during COVID, and we were able to show
that, you know, some people were driving 30 and 45 miles to get a fresh meal for their
family when there was a fresh meal within a one-mile radius.
And so, I think this ability to provide experiential data and to create a local knowledge ecosystem
with community members on the ground, has all kinds of benefits, real-time benefits.
The last example was the number of farmers markets, right?
The last speaker was talking about they created two farmers markets where before there weren't
any same in our projects, right?
We were able to create multiple farmers' markets in different neighborhood environments that
previously didn't exist.
And our partnership and then I'll pass it to other speakers, and our partnership with
Enterprise Community Partners, we had four million people who actually participated in
that project around access, the relationship between housing and access to fresh, affordable,
healthy food.
So, we've been able to have some huge social impact in the projects that we've been in.
And thank you so much for that question.
DR. DIANE HARRIS: Sure, there's a quick follow up question about how did you get people to
participate, to contribute to the app?
What were some of your communication and outreach strategies?
DR. ANTWI AKOM: We have a train the trainer’s model.
So, we would come in and either during COVID via video webinar like this or in a pre or
post COVID if we ever get their context, we can show up ourselves and we train the trainers
on how to actually use the platform.
We train the community residents on how to use it.
We also train community-based leaders in the organizations on how to use our platform.
And what we've seen in that work is pretty exceptional.
We have a 7% user growth week after week when you launch this kind of platform and process.
I think many of us are used to doing this kind of work, this engagement work where it's
sort of one and done.
And I think Streetwyze brings to the table this opportunity to do continuous community
engagement.
When people, when the residents themselves feel like participating, they can participate
versus we're having this one workshop and you need to show up.
But you also have to weigh out whether you have childcare that night or do you have to
work that night or these other things.
And we also see 98% of our users contributing content.
So those are some of the metrics that we've seen in our work that we think could really
add value to many of the processes and projects that are out there aiming to transform and
revolutionize food security with our nation's most vulnerable population.
DR. DIANE HARRIS: Thank you.
Moving to Dr. Obadia, thank you for the wonderful work you shared today.
But the questionnaire agrees with everyone else, but they have a few questions.
Does the eligibility requirements for patients to have a specific health need stop you from
doing true prevention work?
Have you been able to enroll children or is the program only targeting adults?
DR. JENNIFER OBADIA: Yeah, so these are good questions.
And I'll say that so we at Project Bread launched our work in this program in April of 2020,
right as the pandemic was starting, but statewide, it all just began in 2020.
So, everything is still new and evolving including what's allowable by the state, what's allowable
by the Centers for Medicaid and Medicare, and sort of what the federal government will
give us permission to do with Medicaid dollars.
So, there's a lot of pieces that are still moving and lots of room for continual growth
and improvement in this space.
The exciting thing is…is that the state really wants to move forward on this and sees
health equity other as a critical top priority.
In terms of working with children or adults, we do work with children actually.
One of our partners is a children's hospital here in Massachusetts, and it...needing to
have a diagnosis is, I think, a little bit tricky.
And so that has been well recognized by all of those who are involved in this work here
in the state.
And so, as we submit our next waiver requests to the federal government, we're looking at,
Masshealth is looking at how children are different from adults and how can we get at kids
before they have a diagnosis as opposed to having to wait for that diagnosis to start
to do this type of work.
So, we're not there yet, but there's full recognition that we need to get there if that
helps answer the question.
DR. DIANE HARRIS: Thank you.
There's another question about determining which rewards at the most impact on health
outcomes?
How did you determine that health outcomes improved in your program?
DR. JENNIFER OBADIA: Yeah, so there's a couple of layers to that and try not to take too
much time to answer, but so from a state level or accountable care organizations are all
looking at total cost of care, use of emergency department and then they each have a different
specific health outcome that they might be looking at.
So A1C level or behavioral health outcomes, things like that.
So, it does differ from organization to organization.
So that's about most fundamental.
And then at our level as a community organization at Project Bread, we're really looking at
self-reported data from the participants.
So, looking at do they feel that they have access to the foods that they need to be healthy?
How do they feel about the process by which they're accessing these foods?
Are there different resources they feel that they need in order to be able to prepare the
types of healthy foods they want for their families?
And then, of course we're looking at some kind of more straightforward numbers like
fruit and vegetable consumption, use the hunger vital signs to determine food security, so
things along those lines.
But we're as a nonprofit really able create more of the texture and and tell the human story
behind an A1C number.
DR. DIANE HARRIS: Thank you for that.
I think we have time to speak in one more question.
This one is for Dr. Gary Webb.
You talked about your community-based evaluation.
Can you talk about that a little bit about how you engage the community in designing
the evaluation?
I saw all your different components, but can you talk a little bit more about how the community
was engaged in that design?
DR. TIFFANY GARY-WEBB: Yeah, so, you know, breaches is that the performance measures and so forth
that we present to CDC are very structured.
So, what we try to do is make sure that we reported the structure to CDC but then we
also added all these other components.
So, I'll just say a couple of things that we did to work with our partners because what
we realized is that a lot of the grassroots organizations did not have the capacity to
participate in something like REACH as a contracted partner.
So, what we did is a lot of racial equity training that included our contractor partners
and our grassroots organizations so that we can really have that perspective come to our team.
That's one of the first things that we did and we did that over the course of a year.
So, we did a two day retreat and then we did affinity groups over a course of a year.
Then what we did is we did focus groups and so forth in our REACH communities.
And the communities are very, very different.
And so, it was really eye-opening just to do them in the separate communities and see
what their concerns are.
We have lots of environmental concerns in our Monongahela Valley community versus some
of the other communities, you know, food access is more of an issue.
So anyway, the combination of focus groups with our residents and pulling in the community
ambassadors, that was really our way of trying to get more grassroots input into the project.
DR. DIANE HARRIS: Thank you.
Well, unfortunately, I think we've run out of time.
I appreciate all of you for your presentations.
Thank you also to the audience for thoughtful questions, and it's been really fun to have
this opportunity to speak with you all.
So now we're going to move on to the final networking break.
You can continue to have discussions for the next few minutes in the networking room.
It's called the networking lounge, so enjoy those conversations when you return at 4:45
to the auditorium, there'll be the final wrap up and the closing session.
Thank you.
DR. ANGELA ODOMS-YOUNG: Welcome back.
We've made it to the end of the food insecurity, neighborhood food environment and nutrition
health disparities, state of the science.
We're very excited about this virtual workshop and we hope that you enjoyed it.
We also hope that you enjoy the networking session right before this closing session.
So, this is the closing of day three and me and my co-chair, Karen Glanz.
We're going to give some closing remarks and just a summary of the workshop and then talk
a little bit about some gaps and opportunities.
I'm going to start out talking about food insecurity and then we're going to, I'm going to turn it
over to Karen, who is going to dig deeper into neighborhood food environments, and then
we will announce the posters and have some acknowledgment.
So, just to summarize, throughout the workshop, we had several excellent presenters really
highlight the state of the science when it comes to food insecurity, both causes, and
consequences of food insecurity, and then the strategies and solutions or potential
strategies and solutions to address food insecurity.
And we talked about these in day two, but I really wanted to just hit the highlights
because one issue that continues to come up is this limited research data, particularly
on certain populations and populations that are at great risk for food insecurity are
young people that are not in college, our Indigenous communities, our population, both
when we think about intersectionality, where race and other conditions like, I mean race
in conditions such as disability.
So, we have issues when it comes to data and a need for more data and an understanding
of these populations.
We need to use diverse methodologies and look at different approaches to understand the
lived experience of those that are food insecure, both in individuals and families.
Further, define nutrition insecurity and nutrition security.
This is a term that's emerging, and we need to have a better understanding of how do you
define nutrition security and how do you measure nutrition security.
Our multi-level determinants, this is a complex issue.
Triple factors that contribute to food insecurity and then multiple consequences, as was highlighted
by several of the speakers associated with food insecurity.
And so, we need to know more about the determinants and causes at multiple levels, particularly
at the social and structural levels, to understand those social and structural drivers of food
insecurity.
And then the intersection between food insecurity and neighborhood food environments.
Many of the communities that have a high rate of food insecurity also are disproportionately
impacted by low food resource environments.
And so, it's important that we look at the intersection between the two.
And then strategies and solutions to address food insecurity.
What do we know about the lived experience of those that participate in food assistance
programs and what are the barriers?
Several the speakers highlighted the issue of stigma and just navigating that managed
process.
The impact of restrictions and incentives.
How do we look at restrictions and incentives and food assistance programs and be able to
encourage and support healthy eating?
Methodological approaches to understand program implementation, there's been several efforts
to address food insecurity and how do we really understand those by using different methodologies?
Understand [inaudible] Particularly with the combination of different intervention strategies
and approaches, how do we maximize and understand what works both in a more controlled experiment
like RCTs, but also with the natural experiments and within the real world?
We had a talk about implementation science and just how important it is to have studies
apply implementation science frameworks so we can understand what's happening and how
do we get to those positive outcomes and improve more equitable access.
And then we have challenges as far as heterogeneity of programs that are implemented in different ways.
We don't have many structural interventions.
So really, how do we address poverty?
How do we address racism and understand the impact of food insecurity and be able to look
at the impact on downstream outcomes such as diet.
Community-driven solutions, our panel, last panel highlighted many community-driven solutions
to foster food insecurity, but also in our day two discussion and our day one discussion
about food sovereignty and more community-driven solutions.
And then how do we decolonize methodologies in use indigenous ways of knowing theories
such as critical race theory to look at food insecurity and apply that land?
I think it's important we kicked off with day one and Alicia Coleman-Jensen, Dr.
Alicia Coleman-Jensen highlighted the recent data on food insecurity, and I think one important
point was the discussion about comparisons by race.
We have this racial gap that's persisted for many years is not new, but one of the things
that was striking was this rise in food insecurity in some populations as compared to others.
And so, it's important that we try to understand why is this if we're going to look at effective
solutions, why do we see differences across different groups?
And many of us, me included, we're interested in the physiological consequences of food
insecurity, such as the physical sensation of hunger, nutritional inadequacy that
results in dietary quality, reduced food intake.
Well, we also have to think about the other parts of food insecurity because it is a multidimensional
concept.
The psychological effects like food anxiety and stress and stigma, social isolation, and
exclusion that happens.
And then just navigating many programs, navigating the community to access food.
And so that's very important for us to not only take the view of diet but also think
broader.
And then several of the speakers really talked about the need to go upstream, and this is
just the adaptation of the Solar and Irwin conceptual framework on social determinants
of health.
And we many times we think about the downstream impact on nutrition.
But we also have to realize as many of our speakers highlighted that these structural
factors are present, and they impact people's privilege and power.
They shape people's material circumstances, their behaviors, their biology, their psychosocial
context.
And so these are really important when we think about moving forward to address those
gaps and maximize the opportunities.
And then in closing, I'm going to turn it over to Karen for her final comment.
But I wanted to just include that, thinking about this is taking an anti-racist and anti-oppressive
approach to really engage those that are most impacted and understand not only what they
are doing, but the context.
And this is particularly important the lens that we use, and I just want to advocate for
us to understand more and take this anti-racist anti-oppressive approach to research, and
I'm going to turn it over to Karen.
DR. KAREN GLANZ: Thanks, Angela.
It's great pleasure to kind of give a few closing thoughts at a fairly high level about
the neighborhood food environment, but also most of my comments apply to food insecurity
as well.
So, I come back to the story of the blind man and the elephant.
Because if we want to make sure we don't leave any elephants in the room that we're ignoring here.
There are many different perspectives.
Each one is only part of the picture.
Food insecurity, neighborhood food environments are really complex.
And as researchers, we feel like a holistic approach is important.
We want a person-centered approach.
We want a community-centered approach.
We want to distinguish the environment, the policies, and the individual behaviors.
And we really need to respect the complexity of it all as we each work collectively on
our pieces of the puzzle.
Want to hit on the issues related to health equity, you've seen this slide before.
Gita Rampersad showed it.
This is a picture that I believe that the Robert Wood Johnson Foundation has kind of
promulgated, and I think it's really important because it distinguishes between equality
and equity, with equity being meeting people where they're at, not just giving everybody
the same bicycle and hoping it works for them.
And it really means increasing opportunities for everyone to live the healthiest life possible,
no matter who they are, where they live, or how much money they make.
We have focused a lot of our attention on disadvantaged groups and disparities groups
defined by race, virality, disability, low education, and so on.
In this workshop, and we've done that because these tend to be the groups at highest need
with diet-related risk factors and health problems with greatest food insecurity and
so forth.
And one question that's always kind of puzzled me and made me think is, you know, how do
we approach the idea of reducing health disparities?
You know, if you just make things worse for the advantaged people, you will have lower
health disparities.
But the situation won't be any better.
A lot of us talk about lifting a rising tide lifting our votes that if we make conditions
better, they can become better for everyone.
And we have very few examples that actually empirically looked into this kind of dilemma.
And the slide that is showing now is a snippet from an article by Althoff and others that
was published in Nature in 2017, where they used global data in many different countries.
This isn't a physical activity area.
I don't know of any analogy in the nutrition area, but they looked at how walkable environments
lower activity inequality.
And their analysis was really interesting in the key finding that interventions focused
on reducing inequality achieved reductions four times greater than population-wide approaches.
So, focusing on the activity poorest and those most in need in terms of healthful eating
and food insecurity living in the poorest nutrition environments, that actually that
is probably the way we should go.
And when you think about it, at a minimum, it's a good way to use limited resources.
Maybe things get too watered down if we just take a more general approach.
So, I think that the focus on disparities and on and reducing inequalities that we've
talked about so much in this workshop is really promising and one that we should continue
to move forward with.
This workshop and listening to all the different speakers has inspired a lot of thinking in
my own mind beyond, you know, what I came into the workshop thinking about.
And one of the things that I think we need, that I put on my wish list, is that to really
move forward in important ways in this field that we really need to increase the fluidity
between research, policy, and practice.
We're not only siloed by diseases, by agencies, we're siloed by nations and different organizations,
both governmental and non-governmental, have their specific mission.
And I think that if we can find more ways to cross over, we may find that we can accelerate
progress.
And that's what I really want to push for in my dreams, in my optimism for the future.
So, a couple of examples we've heard about today, the Healthy Food Financing Initiative
that Chelsea Singleton discussed.
Huge, enormous program with tons of funding.
And yet there's no national-level evaluation.
Now, a national-level evaluation also has to parse out what's happening at different
local levels.
But that feels like a missed opportunity.
NIH, which is the primary sponsor of this workshop, is dedicated to research and increasingly
to applied research and implementation science.
At the same time, we have USDA and CDC who have enormous influence in nutrition, obesity-related
areas.
But with their emphasis being on policies and programs, with evaluation and research
being secondary, in my ideal world, there would be more crossover between the two.
There would be more leveraging of all programs to try to come up with creative approaches
for research.
We would do things like increase pragmatic trials that may tell us more about how some
of the programs that CDC and USDA are funding or doing.
We would do more than performance monitor.
We would really use some of the current available technologies and leverage them that way.
At the state and local levels those of us interested in health and nutrition need to
work with or the units that work on housing, on safety, and economic development, we've
had some good examples of this today.
These are not revolutionary idea that I'm suggesting, but they're ideas that I think
we need to take on more vigorously if we're going to again, accelerate solutions.
And last in this space, I think that incentivizing collaboration rather than competition could
help us move along faster.
We kind of live in this space where we compete for grants.
We compete for publications.
And yet some of the biggest, gnarliest, most wicked health problems that are being solved
by huge foundations like the Gates Foundation have built a culture of collaboration where
they're accelerating discovery and application of findings by putting in requirements for
collaboration, not just a multicenter trial, but really making sure that people work together.
That, of course, requires us to change some norms in terms of recognition and career development.
But I really think it's something that we could benefit greatly from.
So, to make significant progress in these areas of food insecurity and nutrition environments,
in a nutshell, some of my top six lists, I think we need innovation and flexibility,
collaboration and coordination.
We need to balance internal and external validity.
We could spend a whole afternoon talking about practical ways of collecting scientifically
valid data from disadvantaged populations in ways that aren't biased due to selection.
There's a lot of work to be done in that area.
We need to address supply and demand in the food space.
We need to study individual and aggregate effects, and we always need to keep in mind
the people that are in need that should be driving what we're doing.
I like this quote from the Dalai Lama, who says, "Science and technology are powerful tools.
But we must decide how best to use them.
Perhaps the most important point is to ensure that science never becomes divorced from the
basic human feelings of empathy with our fellow human beings."
And if I may take a slight cue from Mariana Chilton's talk on day one, where she urged
us to find joy in the work we do.
I would say work hard, work smart, and always have fun.
And some of you will recognize Matt Wilpers, one of my favorite Peloton instructors there.
That's a takeoff on one of his catchphrases.
So, I'm going to turn this back to Angela, who will announce the Poster Awards.
DR. ANGELA ODOMS-YOUNG: Thanks, Karen, and I'm very excited about announcing the Poster Awards.
The...we get so many submissions, wonderful submissions, as you noticed when you went
into the poster area on the virtual platform, just phenomenal work that's happening nationally.
The criteria for scoring the awards, the purpose needed to be clearly stated.
The methods and data presented, the quality of that and the quality of the results, the
appropriateness of the conclusions based on the results, and then innovation and potential impact.
So, I'm going to read the, just the name of the first author that received awards and the title.
So, the first award was given to Elizabeth Ackley at Roanoke College and her title was
Advanced Equity and Neighborhood Food Access Insights from a Cohort Initiative.
Juliana, I'm sorry Camargo from [inaudible] Medical Center.
Her title was the Intersection of Food Insecurity, Diet and Gestational Diabetes in Latinas.
Sean Cash from Tufts.
Their title was Household Food Expenditures at Dollar Stores and Implications for Health.
Roger Figueroa, the title was A Latent Profile Analysis of the Food Environment in the Brooklyn
Borough of New York City.
Nora Frank-Buckner and I'm sorry, I forgot to mention that Roger, who was my colleague,
is from Cornell.
How could I miss that?
Nora Frank-Buckner from the Northeast Portland Area Indian Health Board.
The title was COVID-19 Food Insecurity Among American Indian Alaska Natives in Washington
State.
Ana Poblacion from Children's Healthwatch in Boston Medical Center.
The title was Children's Weight Trajectory and its Association with Food Insecurity
and Air Pollution.
Yui Qin from Purdue.
The title was Usual Nutrient Intake of U.S. Older Adults among SNAP Participants and Income-Eligible
Nonparticipants.
Providencia Rocco from Temple, the title was Farm to Families: Food as Medicine in an Urban
Hub.
June Tester from UCSF University of California, San Francisco, and the title was a Recipe4Health:
Clinic-based Approaches for Food Insecurity, and Chronic Disease.
And then the last winner of the award was Rebecca Walker from the Medical College of
Wisconsin, and the title was Medical Expenditures in U.S. Adults Reporting Food Insecurity.
So, congratulations to our award winners, the Scientific Consulting Group will contact
awardees to coordinate the awards.
Please contact Mark Dennis at the email here.
If you have not received the information regarding the awards within two weeks and congratulations,
I'm going to turn it back over to Karen.
DR. KAREN GLANZ: Thank you, Angela.
Now I want to extend our appreciation to everyone who's made this workshop possible.
First, I want to say a special thank you to Angela and Diane.
It's a pretty intense process working on a workshop like this.
And in particular, being in midstream of the workshop trying to keep things going, it's
been a real pleasure and a lot of fun working with Angela as well.
We want to thank our federal sponsors and partners for this workshop.
So, the workshop was officially led by the NIH Office of Nutrition because of the topic
that we've been focusing on.
It was also supported by these other institutes and federal partners at the CDC and USDA.
And what many of you in the audience should really appreciate is that representatives
of each of these institutes and agencies were actively involved in shaping the agenda and
in carrying it out and in helping to make this really come to fruition.
So, we're really grateful to them.
And of course, it couldn't be done without a crowd, and we certainly had an amazing collection
of people working on the organizing committee and support staff.
First, major kudos to Tanya Agurs Collins from NCI and Allison Brown from NHLBI.
They were at the helm.
This has been on their agenda and on their to-do list for, I would say, going on a year
and they did a tremendous job leading us.
Kimberly Barch from the Office of Nutrition Research at NIH has also been steering us
all throughout the way.
There's been a substantial communications team and we want to thank all of our organizing
committee members.
Many of them you've seen who've been either presenters or moderators today and the support
staff at NCI.
And of course, Labroots who was able to help us pull this off in the era of COVID, making
it actually look like it was a real conference with a lobby, a networking lounge, and auditorium,
and all of the above.
Based on the input that we received over the past three days, we'll be developing an executive
summary of that workshop, highlighting key research areas and opportunities, and that
will be published and posted.
And the presentations from the entire three days will be available for viewing beginning
on October 7th online, and they will be up on the Labroots platform for up to a year after
the workshop.
So, if you miss something, if you weren’t able to attend part of the workshop, you’ll
be able to view it afterward.
With that and with thanks for everyone for all your participation, your attention.
We hope that you’ve enjoyed the workshop, learned a few things, and will be able to
make a difference going forward. Thank you all.