Health Equity 101: When Access to Healthy Food is Physically (and Financially) Out of Reach

The JAMA study also found that making minor adjustments around just ten different types of food could have an enormous impact on the risk of death from stroke, heart disease, and Type 2 diabetes. Overconsumption of salt was linked to nearly 10 percent of deaths, for example, while underconsumption of whole grains, fruits, and vegetables contributed to between 6 and 8 percent of deaths.

Poor diet is among the leading causes of preventable suffering. It also disproportionately affects rural, low-income, and minority communities. This is largely due to the existence of food deserts—i.e., areas where residents have to travel more than a mile to reach a grocery store.

According to the United States Department of Agriculture (USDA) data from 2015, some 39.4 million Americans live in low-income, low-access (LILA) areas where accessing nutritious and affordable food is a challenge. That amounts to 12.8 percent of all citizens. In these areas, gas stations and fast-food restaurants become a more convenient and more unhealthy go-to. This is a clear public health issue: when access to healthy food is physically and/or financially out of reach, diet suffers, and the chances of obesity, heart disease, stroke, and diabetes all increase.

Eat Right, also known as the Academy of Nutrition and Dietetics, is an organization dedicated to tackling health equity issues such as food deserts and lack of education. Its mission is to improve the nation’s health through research, advocacy, and education. One way they do this is with their National Nutrition Month campaign.

National Nutrition Month happens each year in March. This month-long education and information campaign aims to increase awareness around healthy eating habits as well as raise the profile of dieticians and nutritionists as essential players in food and nutrition instruction. Throughout the course of the month, there are national and local events aimed at teaching people how to make informed food choices.

The second Wednesday in March is Registered Dietitian Nutritionist Day, which is set aside to celebrate the men and women who have dedicated their careers to helping people enjoy a healthy life through better eating. Here are some ideas of how to get involved with this campaign:

• Work with a local grocery store to promote National Nutrition Month
• Contact the library or local bookstore to host a nutrition book author talk or book signing
• Collaborate with a nearby school to provide National Nutrition Month activities, including coloring sheets, science lesson plans, food group research projects, or nutrition label literacy courses
• Sponsor a food scavenger hunt with your friends and make a nutritious meal with the findings
• Create a workplace email campaign with daily nutrition questions. Hold a prize drawing for people who provided the correct answers
• Help your local school, nursing home, or community center start a garden
• Host virtual cooking classes through social media and teach the nutrition behind the food
• Organize a virtual “ask-a-nutritionist” hour so people can have their food questions answered

Unfortunately, Covid-19 is exacerbating food equity issues. Under pandemic conditions, many more Americans have experienced (and will experience) food insecurity. Online grocery delivery isn’t an option for many of those using food stamps—while the USDA has greenlit food stamps for online delivery options in some areas, 15 states still do not allow redemption of these benefits online. For many vulnerable populations, a reduction in public transportation and a lack of personal transportation mean the challenge of walking long distances to purchase only what one can carry.

Urban Footprint, a data analysis firm, estimates food insecurity could be impacting more than 80 million Americans today, an increase of over 25 million in two months. Compounding the issue is a pandemic-related increase in food prices: the overall cost of groceries increased 2.6 percent in April 2020, with some items, such as eggs, spiking as much as 16 percent. A bad situation is turning worse.

A public health problem is also an economic problem: when health systems respond only to existing diseases, they’re forced to expend enormous resources to treat what’s already a developed condition.

Preventive medicine, on the other hand, seeks to instill healthy habits and provide adequate resources to avoid costly and harmful conditions from developing in the first place. The benefits are not just health-related, but economic as well: research published in Health Affairs found that patients who completed a one-year diabetes prevention program that focused on healthy eating and increased physical activity realized a healthcare savings of approximately $300 per person, per quarter.

Until healthy food becomes easily accessible in all neighborhoods, three steps have to be taken, according to research from Johns Hopkins University. First, healthcare providers should talk with their patients about what to eat and where to find it. Second, community initiatives can provide relief through farmers’ markets, food banks, and mobile food vans. Finally, changes at the policy level need to occur to improve infrastructure and incentivize supermarkets to invest in serving low-income, low-access areas.

All of these steps can be tackled as part of National Nutrition Month, with the support of Eat Right and registered dieticians. To help educate patients, physicians can hire nutritionists and dieticians or sponsor clinics on a regular basis. Community members can utilize Eat Right’s National Nutrition Month promotional materials to provide education on how to utilize the food found in food pantries or offer cooking classes virtually or onsite. For advocacy, Eat Right provides talking points for members to use when they call and talk to their elected officials about policy changes to reduce food inequity.

The Fresh Food Farmacy

Over two thousand years ago, Hippocrates is said to have written: “Let food be thy medicine, and medicine be thy food.” Those words are taken somewhat literally at the Fresh Food Farmacy, a project of Geisinger Health, where patients will find rows of healthy food at no cost and expert education on diet, meal preparation, and associated health conditions.

Under the program, patients who are food insecure and have hemoglobin A1C levels greater than 8 are given a prescription or referral by their primary care provider for the Fresh Food Farmacy.

Once enrolled in the program, patients receive clinical interventions that include care management, diabetes education, and consultations with dieticians and pharmacists. They also receive enough food to prepare ten healthy and nutritious meals for their whole family every week. Through data and analytics, the Fresh Food Farmacy is able to track and analyze outcomes, making adjustments to the program as it gains greater insights.

“As patients entered the program, we saw that food insecurity was not their only social determinant,” says Allison Hess, Vice President of Health for Geisinger’s Steele Institute for Health Innovation. “We quickly added a community health worker to the care team to support additional needs like transportation, housing, budgeting, and other social determinants of health.”

Further observation found that the change in a patient’s diet was so significant that the program needed to adjust medication protocols and many of patients needed additional support in food preparation. At the same time, patients preferred a self-shopping approach when compared to the full-service model. And, while it was expected that the program would lead to other positive clinical outcomes like improvements in weight and blood pressure, Geisinger was encouraged to find higher compliance in preventive care screenings, too.

“The patients’ families were really involved in the process, attending classes with the patients and even engaging in healthier lifestyle activities to show support,” Hess says.

Founded in 2016 at a Geisinger Hospital in Northumberland County, Pennsylvania, the Fresh Food Farmacy now serves more than 200 patients and their families across three locations. Northumberland County is home to an estimated 22,000 adults with prediabetes and has the second-highest rate of long-term diabetes in Pennsylvania. The Fresh Food Farmacy began as a pilot program to address this issue and its relationship to food insecurity. With its success, it’s already expanded to other areas and begun to take other disease states into consideration.

“Geisinger is an integrated delivery system, which makes programs like Fresh Food Farmacy beneficial,” Hess says. “We have a direct referral source for the program and clinical expertise. Additionally, as patients start to better manage their health and lower their costs, it positively impacts our health plan spend.”

For Geisinger Health, the Fresh Food Farmacy is also solving an economic problem. The total direct and indirect costs of diagnosed diabetes in the US was $327 billion in 2017, according to the Centers for Disease Control (CDC). Per-person costs amounted to $9,601 per year.

By comparison, the Fresh Food Farmacy spends an average of $1,000 per low-income patient. Geisinger Health estimates a single point decrease of a patient’s hemoglobin A1C as saving $8,000 in medical costs. So far, several patients of the Fresh Food Farmacy have seen a decrease of three points. By this math, Fresh Food Farmacy isn’t spending money—it’s saving money.

“While we have seen success in our brick-and-mortar approach, we are also working on how to scale to include a larger geography and expand our reach,” Hess says. “We are in the process of piloting a tech solution that will allow us to stay connected to patients in the program and potentially expand to include additional participants.”

The Healthy Food Financing Initiative

America’s Healthy Food Financing Initiative (HFFI) is a public-private partnership between the Reinvestment Fund and USDA Rural Development. Its goal is to improve access to healthy food in underserved areas. Established by the Obama Administration in 2014, HFFI provides resources to fresh and healthy food retailers so that they can overcome the cost burdens associated with moving into food deserts.

So far, HFFI has helped leverage more than $267 million in grants and $1 billion in additional financing, supporting close to 1,000 healthy food vendors across 35 states. It’s also provided technical assistance to a number of initiatives across the country, including the Detroit Black Community Food Security Network (DBCFSN). Technical assistance includes capacity building, identification of food access needs, project planning, market studies, financial modeling, and more.

In May 2020, HFFI made an additional $3 million available in grant funding for food retail and food enterprises working to improve access to healthy foods in underserved areas. Ultimately, the program seeks to provide further capacity building and financial resources that lead to a more equitable food system which supports the physical and economic health of all Americans.

Detroit Black Community Food Security Network

The Detroit Black Community Food Security Network (DBCFSN) was formed in 2006 to address food insecurity in Detroit’s Black community, and organize members of that community to play active leadership roles within the local food security movement.

The centerpiece of the DBCFSN is the D-Town Farm, a community garden which has expanded to seven acres. D-Town Farm is maintained by a small staff and volunteers who grow more than 30 different fruits, vegetables, and herbs through sustainable and regenerative methods. The produce is sold at several locations throughout the community.

DBCFSN also runs a series of youth and educational programs. The Food Warriors program engages young community members in activities designed to teach them about all aspects of the food system: from food justice and environmental awareness to agricultural techniques and healthy food preparation. DBCFSN also sponsors lectures for non-youth audiences on topics such as food, agriculture, health, cooperative economics, community, self-determination, and racial justice.

The role of DBCFSN extends into policy, too. Acting as the lead on a food security task force, they petitioned the City of Detroit to support the creation of a Detroit Food Policy Council (DFPC). Initially chaired by a DBCFSN director, the DFPC continues the self-determined fight for food security and equity in the community. If supported by policymakers and health plans, more communities can, and will, follow suit.

Matt Zbrog

Writer

Matt Zbrog is a writer and researcher from Southern California. Since 2018, he’s written extensively about trends within the healthcare workforce, with a particular focus on the power of interdisciplinary teams. He’s also covered the crises faced by healthcare professionals working at assisted living and long-term care facilities, both in light of the Covid-19 pandemic and the demographic shift brought on by the aging of the Baby Boomers. His work has included detailed interviews and consultations with leaders and subject matter experts from the American Nurses Association (ASCA), the American College of Health Care Administrators (ACHCA), and the American Speech-Language Hearing Association (ASHA).