Healthy Eating for Healthy Communities

F O O D A N D WAT E R Healthy Eating for Healthy Communities SUSAN BRIDLE-FITZPATRICK, PhD “Because of the high prevalence of obesity in our community, we took a close look at healthy eating issues in our community health needs assessment. We wanted to know the social determinants of health, and we wanted to address food insecurity, access to healthy foods and healthy living. That was just a high priority.” —Hospital community benefit director, Northeastern U.S. A n ever-increasing body of research demonstrates that social and environmental determinants of health — factors such as income, employment, safe housing, healthy food, clean water and air, education and neighborhood conditions — exert a powerful influence on health.1 In the United States, the leading causes of death and largest sources of health care expenditure are linked to food and diet: diabetes, heart disease, stroke and some types of cancer. Growing prevalence of obesity has put millions of Americans at increased risk for chronic health conditions as well as poorer mental health and reduced quality of life. Low-income and minority populations are disproportionately affected, with obesity prevalence among black and Latino adults at 47 percent compared to 38 percent among white adults and prevalence among black and Latino children at 22 percent and 26 percent respectively, compared to 14 percent among white children.2, 3 At the same time, 1 in 8 individuals and 1 in 6 children live in households that face food insecurity, or the lack of consistent access to adequate food for an active, healthy life.4 Food insecurity is HEALTH PROGRESS associated with a higher risk of obesity and dietrelated chronic diseases, including diabetes and hypertension. Food insecurity may put people in the position of making trade-offs between healthy food, medicine and other essential needs. One Feeding America study found that 66 percent of food bank client households choose between paying for food and medicine or medical care each year, while 55 percent choose between paying for food and housing. Food insecurity is associated with poorer management of health conditions and greater health care costs, including avoidable emergency department visits.5 HEALTHY FOOD ACCESS IS A VITAL SOCIAL DETERMINANT OF HEALTH The good news is that hospitals and health systems are working to identify and address social www.chausa.org MARCH - APRIL 2019 29 Larry Moore determinants of health in their communities — assessments. Data on diet-related behaviors, such particularly food insecurity and lack of affordable as fruit and vegetable consumption, was included access to fresh, healthy foods. Research from a in 40 percent of CHNAs.10 national study conducted by Health Care WithPerhaps even more important, hospitals are out Harm — Community Benefit and Healthy including community organizations that work on Food: A National Assessment, published in 2018 food access and food system issues in the CHNA — shows growing interest by hospitals to address process. Forty-five percent of hospitals included healthy food access and healthy eating as part of at least one food-related organization, such as their community benefit/community health pro- food banks or food policy councils, on their CHNA grams.6 Health Care Without Harm is an inter- steering committees.11 Engaging community food national coalition that works closely with Practice Greenhealth, the leadEngaging community food ing nonprofit membership and network organization for environmenorganizations in the CHNA tally sustainable health care, serving more than 1,200 hospital members process leads to a more nuanced throughout the United States. Hospiunderstanding of food-related tals around the country are embracing the fact that affordable access health needs as well as resources to healthy food is critical not just to and opportunities to effectively preventing and treating diet-related health conditions, but also to building address these needs. thriving communities, strong local economies and sustainable food systems.7 Community benefit represents a powerful organizations in the CHNA process leads to a opportunity to promote community well-being more nuanced understanding of food-related health needs as well as resources and opportunithrough healthy food. ties to effectively address these needs. UNDERSTANDING FOOD-RELATED HEALTH NEEDS AND OPPORTUNITIES Health Care Without Harm’s comprehensive study revealed important trends in hospitals’ community benefit activities to understand and address food access and diet-related health needs in their communities.8 The study’s nationally representative survey of hospital community benefit directors found that in their most recent community health needs assessment (CHNA), 71 percent of hospitals identified obesity as a health issue in their communities.9 Other selected health needs identified in CHNAs include: 40 percent–Diabetes 45 percent–Other diet-related diseases 13 percent–Food insecurity or healthy food access 22 percent–Poverty, economic security or unemployment More and more hospitals — 57 percent of survey respondent facilities — are collecting information about the quality of community food environments, such as the prevalence of U.S. Department of Agriculture “food deserts,” in their 30 MARCH - APRIL 2019 HOSPITAL COMMUNITY BENEFIT PROGRAMS PROMOTE HEALTHY FOOD ACCESS AND HEALTHY EATING Hospitals across the country are participating in diverse community benefit programs to address obesity, healthy eating and diet-related health conditions. Diet and nutrition education and exercise promotion are the most common interventions. However, health professionals understand that although they may encourage patients to eat five servings of vegetables and fruits each day, if families are struggling with food insecurity, it will be difficult to adhere to those recommendations. Working with community partners, many health systems are making healthy food and healthy eating more accessible, convenient, affordable — and even fun. Screening for Food Insecurity When health care providers assess patients for food insecurity, they can help overcome the stigma of not having consistent access to food. They can identify a vulnerable target population, tailor clinical care to real patient needs, help reduce the prevalence of food insecurity and its www.chausa.org HEALTH PROGRESS F O O D A N D WAT E R effects on the community, and potentially reduce health care costs by reducing preventable emergency department and provider visits. Health systems such as Providence Medical Group, based in Oregon, use a “screen and intervene” strategy. It includes screening for food insecurity (for example, by using the Hunger Vital Sign two-question food insecurity screening tool), identifying food insecurity in patients’ electronic medical records, and connecting food-insecure individuals and families to food resources. Food Banks and Pantries Food banks play a central role in the network of national, regional and local organizations working together to address the needs of food insecure communities across the nation. Hospitals can support food banks and pantries in their efforts to provide fresh, healthy food for their clients. From hosting food pantries onsite to offering diet and nutrition education to investing in refrigerators, hospitals are partnering with food banks to improve community food security and health. St. Vincent Randolph, a critical access hospital in Winchester, Indiana, donated funds to purchase refrigerators for the Community Food Pantry to support sourcing and providing clients with fresh produce. The Winchester Area Community and Churches Food Pantry also is located on the St. Vincent Randolph campus. Fruit and Vegetable Incentive Programs Fruit and vegetable incentive programs, such as Double Up Food Bucks and “prescriptions” for produce, reduce economic barriers that some families face when purchasing fresh, healthy foods. Hospitals are partnering with programs that increase produce purchasing power by doubling the value of Supplemental Nutrition Assistance Program resources or by providing prescriptions with vouchers that can be redeemed for fresh fruits and vegetables. Seattle Children’s Hospital in Washington has provided grant support to help fund Fresh Bucks Seattle, the city’s fresh produce incentive program. Program evaluators found that 89 percent of surveyed participants reported eating more fruits and vegetables because of Fresh Bucks. Farm-To-School Farm-to-school experiences are associated with students’ increased consumption of fruits and vegetables. Farm-to-school activities range from HEALTH PROGRESS buying food from area farmers to serve at schools, to farm field trips, to hands-on learning in a garden, cooking demonstrations and integration of food-related information into classroom curricula. Hospitals can enhance farm-to-school activities, which support students’ health while strengthening local and regional food systems. Orlando Health, a health care network in central Florida, created the Healthy Living Garden at Orange Center Elementary in that city to interest and teach students about food, health and nutrition. Located in an area where exposure to fresh, healthy food is limited, the garden gives 345 students access to fresh produce and the opportunity to participate in garden-based health and education activities. Meal Programs Summer, after-school and weekend meal programs give low-income children vital access to nutritious foods when school is not in session. The USDA’s Summer Food Service Program and the Child and Adult Care Food Program provide funding to state agencies that coordinate with locally based sponsors to operate programs. Hospitals can play key roles, whether operating onsite meal programs or supporting other efforts in their communities. Reading Hospital in Pennsylvania was a partner in an initiative to create a summer meal site at a public housing complex, next to the Berks Community Health Center, a federally qualified health center. The hospital contributed funding to upgrade a picnic pavilion to meet requirements for meal program sites. The meals include fresh local produce, and the clinic offers free screenings as well as wellness and nutrition programs to children and families. Farmers Markets and Mobile Markets Hospitals throughout the United States host farmers markets to create healthier community food environments and promote healthy eating behaviors. Farmers markets in all 50 states now accept SNAP benefits; between 2012 and 2017 farmers markets nationally saw a 129 percent increase in the number of SNAP authorized sites and a 35 percent increase in SNAP redemptions.12 Florida Hospital (now AdventHealth Orlando) awarded a grant to Fresh Stop — a fruit and vegetable market on wheels — to outfit a bus with special refrigerated racks for fresh vegetables and fruits. The Fresh Stop bus delivers fresh, healthy www.chausa.org MARCH - APRIL 2019 31 food to 16 locations in food desert neighborhoods. Supported by the central Florida community, the service sells produce at discounted prices, provides nutrition education and even offers cooking tips. Healthier Corner Stores Healthier corner store initiatives increase and promote healthy food options in small retail settings. Hospitals can partner with public health departments and local agencies to enhance these efforts by providing funding, training and resources to help store owners stock and promote healthy food choices. Montefiore Medical Center’s Healthy Store Initiative works with Jetro, the primary supplier for New York City bodegas, and corner stores in neighborhoods with high rates of obesity. Stores Community-Supported Agriculture Community-supported agriculture, or CSA, programs provide members with a box or a “share” of fresh, local fruits and vegetables and other farm products that are in harvest at the time of weekly distribution. CSA programs not only can increase access to fresh, healthy foods for vulnerable households, but they also can supA food policy council is a group of port farmers and keep food dollars circulating in the local economy. stakeholders that addresses foodSince 2013, Presbyterian Healthcare related needs within a designated Services, a health care system in New Mexico, has provided funding to subsiregion. Food policy councils include dize La Cosecha CSA shares to ensure that the CSA is affordable for low-income a diversity of sectors and industries families without jeopardizing the ability as well as public, private and of the farmers and farmworkers to earn a fair wage. Each week the CSA shares are nonprofit organizations. accompanied by a nutrition education handout written in English and Spanish that includes information about the farms as well receive promotional materials and technical assisas nutrition guidance, kid-friendly recipes and tance on how to promote healthy items and a Shop Healthy NYC designation when they achieve prostorage tips related to that week’s produce. gram goals. Montefiore also partners with community organizations on “Adopt a Shop” activities Food Policy Advocacy A food policy council is a group of stakeholders for nutrition education and to drive demand for that addresses food-related needs within a des- healthy products. For more information on healthy food access ignated region. Food policy councils include a diversity of sectors and industries as well as pub- and healthy eating efforts, the “Delivering Comlic, private and nonprofit organizations. Their munity Benefit: Healthy Food Playbook” proprimary goals align closely with those that health vides practical guidance for hospitals interested care institutions also care about deeply: address- in working with community partners to impleing food insecurity, healthy food access, regional ment these and other healthy food programs, economic development and environmental sus- including examples and lessons learned from across the U.S.13 tainability, among others. St. Joseph Mercy Ann Arbor Hospital in Michigan has a seat on the Washtenaw County Food TRIPLE WIN STRATEGIES Policy Council, which has joined other local When developing food programs, strategies can councils to successfully advocate for an expan- be integrated to accomplish three complementary sion of state funding for the 10 Cents a Meal for goals: improve access to healthy, affordable food; School Kids & Farms program. This pilot pro- support economic and workforce development in gram provides schools with up to 10 cents per low-income communities; and strengthen local meal in match funding to purchase and serve and sustainable food systems. Michigan-grown fruits, vegetables and legumes. Interventions that address healthy food access The program for the 2016-17 school year provided with this kind of “triple win” strategy address 48,000 students in 16 school districts with 49 dif- social and environmental determinants of health ferent Michigan-grown foods from 86 farms. as part of a transformative community develop- 32 MARCH - APRIL 2019 www.chausa.org HEALTH PROGRESS F O O D A N D WAT E R county public health department. It truly ment framework. Initiatives such as communitydoes involve collaboration. There are a lot of supported agriculture, fruit and vegetable prereally great resources that currently exist in scription programs, mobile farmers markets, and the community. It’s about raising awareness farm-to-school programs can increase access to of those resources and connecting the dots. healthy and affordable food while creating jobs in I’m very interested in designing sustainable underserved communities and localizing the food efforts, and we have found that it doesn’t nececonomy. essarily cost a lot of money to be a strategic Community benefit is only one of many ways partner.” that hospitals and health systems invest in the health and well-being of their communities. As —Hospital community benefit director, anchor institutions — large, nonprofit organizaWestern U.S. tions that, once established, tend to remain rooted in place — hospitals are increasingly recognizing Health care facilities can’t improve the social their “anchor mission” to harness their significant and environmental determinants of health alone. economic and other resources to address social Such change requires a collaborative, communityand environmental determinants of health in the wide effort. In Community Benefit and Healthy communities they serve. Food: A National Assessment, community benefit Anchors in Resilient Communities is a multi- professionals emphasized their reliance on partsector collaborative coordinated by Health Care nerships with community organizations not only Without Harm and Emerald Cities Collaborative to understand food-related health needs in their to leverage the assets and capacities of anchor communities but also to design, implement and institutions and community-based partners in evaluate successful healthy food programs. ColSan Francisco East Bay, with a focus on strength- laboration with community partners is essential ening the health, wealth and resilience of com- to: munities of color and low- and moderate-income Reveal gaps, areas of need and opportuniresidents. The collaborative’s initial project, ties to strengthen current assets My-Cultiver, is focused on building a healthy regional food sysInitiatives such as communitytem and strengthening the local food economy. My-Cultiver aims supported agriculture, fruit and to produce 200,000 healthy and vegetable prescription programs, locally sourced ready-to-eat meals per day to distribute to hospitals, mobile farmers markets and farmschools and other institutions through long-term contracts. The to-school programs can increase initiative also will create union access to healthy and affordable food jobs and cooperative ownership opportunities. while creating jobs in underserved Kaiser Permanente plays a unique role in supporting the communities and localizing the food development and implementaeconomy. tion of ARC and My-Cultiver by providing community benefit and other investments and purchasing commitments. Align with existing community efforts or Kaiser Permanente also serves on the ARC advi- bring groups and organizations together for sory committee and on several working groups. greater coordination and synergy Develop more effective and appropriate WHY PARTNERSHIPS MATTER strategies and approaches by consulting experts in the field with experience addressing food system and equity issues “Hospitals are not going to fix all the problems that we identify in our needs assessStrengthen relationships to improve reach, ments. It’s not something that’s going to be impact and long-term sustainability of efforts remedied solely by hospitals or solely by your Avoid duplication of programs and services HEALTH PROGRESS www.chausa.org MARCH - APRIL 2019 33 In addition, there are numerous ways that hospitals can provide community benefit support for healthy food access programs, including contributing staff time and expertise, other in-kind contributions and financial resources. Health Care Without Harm’s research identified nine common role categories that hospitals are playing in support of healthy food access programs: Provide grant support Provide use of hospital facilities Conduct food insecurity or other health screening Conduct nutrition, food or cooking education Provide staff or financial support for program evaluation Provide staff support for grant writing or securing sustainable funding of community benefit initiatives Manage or coordinate a program or community collaboration Participate in a community collaboration Advocate for healthier food policies The healthy food playbook’s guidance brief on “identifying community partners” can help facilities identify community organizations that can be critical partners in healthy food access initiatives, while its resources on “hospitals’ community benefit roles” discusses diverse roles hospitals can play, with examples.14 CONCLUSION Hospitals around the country are embracing the fact that affordable access to healthy food is critical not just to preventing and treating diet-related health conditions, but also to building thriving communities, strong local economies and sustainable food systems. Still, an obstacle for many hospitals to investing in improving social determinants is the challenge of measuring return on investment in terms of reduced health care utilization and cost. Some hospitals across the country are beginning to identify these positive impacts but need more time to test and evaluate programs. While it is challenging, securing continued investment in social determinants of health requires that health care organizations collaborate with community partners to demonstrate impact. A broader, longer-term approach to identifying social return on investment—in which socioeconomic and environmental results are assessed 34 MARCH - APRIL 2019 together with traditional financial measures—can be advanced through multisector collaborations in which schools, health care organizations, social service providers and other community organizations coordinate services and share data.15 Such collaboration can assess diverse impacts of social determinants of health interventions over a longer time period, potentially capturing improved health status, higher high school and college graduation rates, and increased employment and earnings in underserved communities. Community benefit professionals can tell the story of the impact of community health improvement initiatives in terms of multiple forms of return on investment. This also can include a more engaged health care workforce. Staff members at hospitals that invest in social determinants of health may feel more inspired, committed and engaged in their work — proud and enthusiastic to be part of a health care organization that makes a difference in the community. SUSAN BRIDLE-FIZPATRICK is principal at Healthy Food Strategies, a research and policy analysis consulting firm; adjunct faculty at the University of Denver; and former senior researcher at Health Care Without Harm. NOTES Research and resources developed by Health Care Without Harm’s national Healthy Food in Health Care program, with support from the Robert Wood Johnson Foundation, are the basis for much of this article. Research assistance was provided by Jessica O’Toole, Dan Myers, Morgan Fleming, Betsy Skoda and Nicki Milgrom. The Healthy Food in Health Care program harnesses the purchasing power and expertise of the health care sector to promote a healthy, equitable and sustainable food system. More information at healthyfoodinhealthcare.org. 1. Hyojun Park et al., “Relative Contributions of a Set of Health Factors to Selected Health Outcomes,” American Journal of Preventive Medicine 49, no. 6 (December 2015): 961-69. 2. Centers for Disease Control and Prevention website, “Adult Obesity Causes and Consequences,” www.cdc. gov/obesity/adult/causes.html and “The Health Effects of Overweight and Obesity,”www.cdc.gov/healthyweight/effects/index.html. 3. Craig M. Hales et al. “Prevalence of Obesity Among Adults and Youth: United States, 2015–2016,” NCHS www.chausa.org HEALTH PROGRESS F O O D A N D WAT E R Data Brief, no. 288. Hyattsville, MD: National Center for Health Statistics. 2017, www.cdc.gov/nchs/products/ databriefs/db288.htm. 4. “Map the Meal Gap 2018,” report on the Feeding America website, www.feedingamerica.org/sites/ default/files/research/map-the-meal-gap/2016/2016map-the-meal-gap-all-modules.pdf. 5. “Hunger in America 2014,” report on the Feeding America website, http://help.feedingamerica.org/HungerInAmerica/hunger-in-america-2014-full-report.pdf. 6. “Community Benefit and Healthy Food: A National Assessment,” report on Health Care without Harm’s website, https://foodcommunitybenefit.noharm.org/ research-reports/community-benefit-and-healthyfood-national-assessment. This assessment included a representative survey of community benefit directors at private, tax-exempt general hospitals, a review of surveyed hospitals’ community health needs assessments and community benefit implementation strategies, and over 100 in-depth interviews. The research examined the hospital community benefit landscape and identified promising practices to promote affordable access to healthy food and healthy eating to address risk of dietrelated health conditions. 7. “Toward a Healthy Sustainable Food System,” American Public Health Association website, https://www. apha.org/policies-and-advocacy/public-health-policystatements/policy-database/2014/07/29/12/34/ toward-a-healthy-sustainable-food-system. 8. “Community Benefit and Healthy Food: A National Assessment.” 9. “Community Benefit and Healthy Food: A National Assessment.” HEALTH PROGRESS 10. “Delivering Community Benefit: Healthy Food Playbook,” on the Health Care Without Harm website, https://foodcommunitybenefit.noharm.org/. The playbook is a suite of resources to support hospital community benefit professionals and community partners in developing community health interventions that promote healthy food access and healthier food environments. “Data Sources to Assess Food Access, Environments, and Behaviors in CHNAs” in the playbook is a practical guide to useful data sources, https://foodcommunitybenefit.noharm.org/resources/ community-health-needs-assessment/data-sources. 11. See the guidance brief “Engaging the Community to Understand Food Needs” in the playbook to learn more, Health Care Without Harm website, https://foodcommunitybenefit.noharm.org/ resources/community-health-needs-assessment/ engaging-community-understand-food-needs. 12. “Comparison of SNAP Authorized Farmers Markets FY2012 to FY2017,” U.S. Department of Agriculture website, https://fns-prod.azureedge.net/sites/default/files/ snap/SNAP-Farmers-Markets-Redemptions.pdf. 13. “Delivering Community Benefit: Heathy Food Playbook.” 14. “Delivering Community Benefit: Healthy Food Playbook.” 15. “Social Return on Investment,” Innovation Center Issue Brief (American Public Human Services Association, May 2013), https://33igt8427g0w69zms 33dqm48-wpengine.netdna-ssl.com/wp-content/ uploads/2014/06/Social-Return-on-Investment-Brief. pdf. www.chausa.org MARCH - APRIL 2019 35 JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES www.chausa.org HEALTH PROGRESS ® Reprinted from Health Progress, March-April 2019 Copyright © 2019 by The Catholic Health Association of the United States