Food Insecurity Public Health and Healthcare Provider Engagement
Food Insecurity, Public Health, and Healthcare Provider Engagement Hilary Seligman, MD MAS Associate Professor of Medicine and of Epidemiology & Biostatistics, UCSF Food Policy, Health, and Hunger Program, UCSF Center for Vulnerable Populations Senior Medical Advisor and Lead Scientist, Feeding America Director, CDC’s Nutrition and Obesity Policy Research and Evaluation Network
Disclosures: I have no commercial conflicts of interest to disclose. Opinions expressed in this presentation are my own and do not necessarily reflect the opinions of any of my funders, including Feeding America, CDC, USDA and NIH. BROWN • MILLER COMMUNICATIONS
Learning Objectives • Articulate the connection between food insecurity & chronic disease • Define two models of community engagement • Lessons learned from working in community settings BROWN • MILLER COMMUNICATIONS
FOOD INSECURITY AND CHRONIC DISEASE BROWN • MILLER COMMUNICATIONS
• Food security: Access by all people at all times to enough food for an active, healthy life • Food insecurity: Household-level economic and social condition of limited or uncertain access to adequate food United States Department of Agriculture
Hunger The uneasy or painful sensation caused by a lack of food, or the recurrent and involuntary lack of access to food. (LSRO)
Coping Strategies to Avoid Hunger • Eating low-cost foods – Fewer F&V – More fats/carbs • Eating highly filling foods • Small variety of foods • Avoiding food waste • Binging when food is available • Higher risk of obesity, diabetes, & other chronic, diet-sensitive chronic disease • Once you are chronically ill, poorer ability to manage it your illness
Evolution of Research on Health and Socioeconomic Status Disparities Exist The Problem is a Big One Interventions Can Help Address the Problem BROWN • MILLER COMMUNICATIONS
Evolution of Research on Health and Food Insecurity & Health are Related The Problem is a Big One Interventions Can Help Address the Problem BROWN • MILLER COMMUNICATIONS
Food Insecurity & Health are Related The Problem is a Big One Interventions Can Help Address the Problem BROWN • MILLER COMMUNICATIONS
Seligman & Berkowitz, Aligning Programs and Policies to Support Food Security and Public Health Goals in the United States. Annual Review of Public Health, 2019.
Nutritional Mental Health Behavioral
These are not theoretical. All of have been shown in multiple research studies. Nutritional Macro- & micronutrient def Obesity Mental Health Anxiety/stress Depression Drug/alcohol/tobacco use Behavioral Treatment non-adherence Postponing care Missed clinic visits Weiser, Palar, et al. Food Insecurity and Health: A Conceptual Framework. Chapter in: Food Insecurity and Public Health. CRC Press, 2015.
STRESS Nutritional Macro- & micronutrient def Obesity Mental Health Anxiety/stress Depression Drug/alcohol/tobacco use Behavioral Treatment non-adherence Postponing care Missed clinic visits
Food Insecurity & Health Across the Lifespan • Kids: iron-deficiency anemia, behavioral problems, mental health symptoms, poor cognitive development & academic achievement, hospitalizations, ? obesity • Adults: obesity (women), diabetes, high blood pressure, heart disease, depression, hospitalizations, emergency room use, psych emergency room use • HIV: poorer viral suppression, decreased medication adherence • Elderly: reduced ability to live in community Food Insecurity Poor Health These are just a few of the MANY associations.
Food Insecurity Diabetes Tait, C. A. , et al. (2018). "The association between food insecurity and incident type 2 diabetes in Canada: A population-based cohort study. " Plo. S one 13(5): e 0195962. BROWN • MILLER COMMUNICATIONS
Food Insecurity Diabetes People living in food insecure households had more than TWICE the risk of developing diabetes even after accounting for differences in age, gender, race, physical activity, smoking, alcohol, and diet quality. Tait, C. A. , et al. (2018). "The association between food insecurity and incident type 2 diabetes in Canada: A population-based cohort study. " Plo. S one 13(5): e 0195962. BROWN • MILLER COMMUNICATIONS
Food Insecurity & Health are Related The Problem is a Big One Interventions Can Help Address the Problem BROWN • MILLER COMMUNICATIONS
1 9 Why Talk About Costs? • Food security interventions and programs are designed to feed people, not to save health care costs – Strong incentives for health systems to reduce costs – Cost is a “common currency” that may align sectors: tension between traditional role of public health, health care, and social safety net • Costs have been an accessible way to articulate the scope of the problem • Documenting excess health costs may be part of the solution: support programs & policies BROWN • MILLER COMMUNICATIONS
Berkowitz, Seligman, et al. AJMC, 2018.
Food Insecurity & Subsequent Annual Health Care Expenditures 7000 $ [VALUE] 2015 US Dollars 6000 5000 $ 1863 $ [VALUE] 4000 3000 2000 1000 0 Food Secure Food Insecure NHIS-MEPS data adjusted for: age, age squared, gender, race/ethnicity, education, income, rural residence, and insurance. Berkowitz, Basu, and Seligman. Health Services Research: 2017.
$77. 5 billion additional health care expenditures annually Berkowitz, Basu, and Seligman. Health Services Research: 2017.
Food Insecurity & Health are Related The Problem is a Big One Interventions Can Help Address the Problem BROWN • MILLER COMMUNICATIONS
Reduces food insecurity by 20 -30% BROWN • MILLER COMMUNICATIONS
Number of admissions for low blood sugar, per 100, 000 total admissions Admissions for Low Blood Sugar Increase by 27% in Last Week of the Month for Low-Income Population Low-income All Not low-income Can make a difference? Admission Day of Month Seligman HK et al. Health Aff 2014; 33: 116 -123 © 2014 by Project HOPE - The People-to-People Health Foundation, Inc.
American Recovery & Reinvestment Act May 2009 -October 2013
2 7 $54 million averted Emergency department and inpatient hospitalization costs only for commerciallyinsured adults between the ages of 19 and 64 Basu S, Berkowitz SA, Seligman HK. Medical Care. 2017. BROWN • MILLER COMMUNICATIONS
Berkowitz, Seligman, et al. JAMA Int Med. 2017
Berkowitz, Seligman, et al. JAMA Int Med. 2017
SNAP & Pregnancy Outcomes • 20% of SNAP recipients are women of childbearing age • Medicaid recipients in Missouri • SNAP benefits later in month associated with reduced pregnancy-related ER visits • Higher benefit amounts associated with increased effect Arteaga, Heflin, & Hodges. Pop Res & Pol Rev, 2018 BROWN • MILLER COMMUNICATIONS
Probability of Pregnancy-Related ER Visit, % Higher SNAP Benefits Associated with Lower Pregnancy-Related ER Visits 9 8. 5 8 7. 5 7 6. 5 6 75 175 275 375 475 Monthly SNAP Benefit, $ 575 675 Arteaga, Heflin, & Hodges. Pop Res & Pol Rev, 2018
SNAP Benefits Also Reduce Child ER Visits for Asthma • Higher SNAP benefits correlated with lower probability of asthma-related ER visit – $275/month: 5. 73% – $675/month: 5. 43% • Especially pronounced at lower benefit levels – $175 to $275 increase in benefits decreases the likelihood of asthma-related ER visits by about 784 per 100, 000 – $575 to $675 increase in benefits decreases the likelihood of asthma-related ER visits by about 751 per 100, 000, a 14% decrease in claims • Mechanism partially through “cost-related medication non-adherence”? Heflin, Arteaga, et al. Soc Sci & Med, 2019 BROWN • MILLER COMMUNICATIONS
SNAP & High Blood Pressure Visits to Emergency Room • As SNAP benefits increased, probability of an ER visit for HBP decreased – $100 increase in SNAP benefits will reduce HBP claims by 638 visits per 100, 000 – Especially pronounced at lower benefit amounts • HBP ER visits also likely to be partially related to “cost related medication non-adherence”? Ojinnaka & Heflin. Jl Am Soc Hypertens, 2018. BROWN • MILLER COMMUNICATIONS
Among MFS, LFS, & VLFS older adults, SNAP reduces CRMN by 9. 1%
SNAP Prevents Hospitalizations Among Older Adults in Maryland • Medicare/Medicaid “dual eligibles” • SNAP associated with 1. 5% decreased risk of hospitalization • Once hospitalized, SNAP associated with 5. 8% lower expenses • $10 increase in monthly SNAP associated with 2% lower odds of either hospitalization or ER visit • Enrolling the 47% of the 2012 SNAP-eligible nonparticipants could have saved $19 million in hospital costs • Medicaid also made an enormous difference Samuel, Szanton, et al. Pop Hlth Mngmt, 2018. BROWN • MILLER COMMUNICATIONS
Medicaid Expenditures Decreased During ARRA Interrupted time series analysis of changes in nationwide inpatient Medicare expenditures in response to changes in SNAP, January 2006–January 2014. SNAP benefits increased monthly by a minimum of 13. 6% per SNAP household in April 2009, and this increase expired in November 2013. Sonik, Parish, & Mitra. Prev Chr Dis, 2018.
WIC Important Too • WIC ppts have fewer still-births, esp. in high-risk women (including African-Americans) • Prenatal WIC ppts have lower incidence of ADHD, other common child mental health conditions, and grade repetition compared with siblings • WIC ppts have higher utilization of well-child visits, vaccinations, and ER • WIC ppts have lower utilization of hospital in first year of life Angley et al. BMC Preg & Cldbrth, 2018 Chorniy, Currie, & Sonchak. NBER 24691. 2018 Bersak. Hlth Serv Rsrch, 2018. BROWN • MILLER COMMUNICATIONS
Other Interventions • Home delivered meals for 6 months for dualeligibles – Medically tailored or non-tailored meals reduced ER visits & reduced medical spending – Medically tailored meals reduced hospitalizations Berkowitz, et. BROWN • MILLER al. Hlth Aff, 2018 COMMUNICATIONS
Where are we in early 2019? • Food insecurity is DEFINITIVELY linked with poor health and higher health care utilization. • Some of this relationship is poor health causing food insecurity; some of this relationship is food insecurity causing poor health. Food Insecurity & Health are Related The Problem is a Big One Interventions Can Help Address the Problem BROWN • MILLER COMMUNICATIONS
Where are we in early 2019? • Food insecurity more than doubles diabetes risk. • Food insecurity is associated with ER use and hospitalizations. • Annual health care expenditures associated with food insecurity are enormous. Food Insecurity & Health are Related The Problem is a Big One Interventions Can Help Address the Problem BROWN • MILLER COMMUNICATIONS
Where are we in early 2019? • SNAP works • WIC likely works • Home delivered meals—data is suggestive Food Insecurity & Health are Related The Problem is a Big One Interventions Can Help Address the Problem BROWN • MILLER COMMUNICATIONS
Screen and Intervene Identification of food insecurity by positive clinical screen Referral to entity managing connection to federal or community program Enrollment in federal or community food program Improved diet quality, food security, and clinical satisfaction Improvement of health and utilization outcomes BROWN • MILLER COMMUNICATIONS
Resources for Food Insecure Households Federal Nutrition Programs SNAP WIC NSLP, SBP, TEFAP, CSFP, etc Charitable Feeding System Food banks & food pantries Home delivered meals & medically tailored meals Informal Social Support Personal Income/ Budget Shifts Friends & family Community resources, eg religious institutions Tradeoffs between food and personal hygiene products, utilities, medications, gas, rent, etc. Free dining rooms (soup kitchens) Vouchers (local programs or part of SNAP) BROWN • MILLER COMMUNICATIONS
Two Models of Community Engagement Leveraging an Existing CBO Infrastructure • Partner with a CBO, add your unique skills to their unique skills Developing Your Own Infrastructure • Creating your own program
The Feeding America Network 200 MEMBER FOOD BANKS AMERICANS 1 NATIONAL OFFICE 60 K 46 M SERVED ANNUALLY FOOD PANTRIES AND MEAL PROGRAMS
• Biggest advantage to this model: Leverages infrastructure of an entire organization – Established reputation – Communications expertise, especially helpful for framing your issue – Infrastructure for advocacy, grant-writing, interventions, & dissemination of findings – Meeting the right people
• Biggest advantage to this model: I have at my disposal an entire organization • Challenges in working with an organization in this way – Navigating the line between advocacy and science – Negotiating who owns the content
Our Goal By 2025, Feeding America, in collaboration with our network and our partners, will ensure access to enough nutritious food for people struggling with hunger and make meaningful progress toward ending hunger.
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Blood Sugar Monitoring Food Diabetes Education Referral to Primary Care
• Diabetes food boxes and self-management support at the food pantry – Reduced food insecurity, improved dietary intake – Did not improve diabetes self-management or blood sugar control Seligman, et al. AJPH, 2018.
Two Models of Community Engagement Leveraging an Existing CBO Infrastructure • Partner with a CBO, add your unique skills to their unique skills Developing Your Own Infrastructure • Creating your own program
FRESH PRODUCE FOR ALL SAN FRANCISCANS
5 5 • Advantages to this model – We can make all of the decisions so that they are maximally effective to achieve our priorities. – We have had HUGE impact in a short period of time • Challenges – My team has to do all the work and learn many, many new skills. – We are responsible for keeping the program running. • Logistics of a network of stakeholders, CBO’s, food vendors, and financial personnel. – We need ongoing funding. BROWN • MILLER COMMUNICATIONS
We Are On the Right Track • Individual participants • Increase F&V intake by 1 serving daily • More food secure • Greater confidence in making healthy food choices on a budget • Improved health status & quality of life • Vendors • New customers • Increased revenue • Higher produce turnover, less food waste
Skills Learned in this Process • • • • Running a non-profit Communications/media externally and internally Political savvy How to be a service provider for a government entity Strategic planning process Program scaling Establishing and running a Board University reimbursement systems Program QI processes outside of academic research Complex budgeting processes Navigating gaps in funding for a program Fundraising strategies: individual & corporate focus Technology of debit cards Working with food vendors … I am not trained in most of these skills. Neither are typical physicians. BROWN • MILLER COMMUNICATIONS
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Things I Have Learned Doing Community Advocacy & Research Community engagement is not traditionally rewarded at academic institutions, health systems, or other physician employers. Highlight for your employer the ways your advocacy benefits them.
6 0 Things I Have Learned Doing Community Engaged Advocacy & Research It is easy to overstretch. Focus on what you are most passionate about because there are more opportunities than you will have the bandwidth to participate in.
6 1 Things I Have Learned Doing Community Engaged Advocacy & Research There WILL BE more false starts than true starts. Find the low-hanging fruit wherever you can.
6 2 Things I Have Learned Doing Community Engaged Advocacy & Research I have developed tremendous skills, made essential connections, and created impact from community work that was not officially part of my job. Food Security Task Force Board of Directors Policy/advocacy engagement
Local Politics • Real change happens at the local level • San Francisco Board of Supervisors: Food Security Task Force – Member of the public voting member representing hospitals & health care
Hilary Seligman, MD MAS Hilary. Seligman@ucsf. edu championprovider. ucsf. edu
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