How to Curb Food Insecurity in Patients?

Marcia Frellick

November 25, 2019

Unhealthy diet has been shown to lead to diabetes, cardiovascular disease, and cancer, but in many pockets of the United States, sustainable access to healthy food remains out of reach. On that, experts agree. But solutions to address the problem are wildly diverse and evolving.

Over the past couple of years, ideas have come from a variety of sources, including a nonprofit voucher program, the rideshare company Lyft, low-cost subscription meal delivery through the nonprofit arm of Blue Cross Blue Shield, and food banks in Geisinger medical centers specifically for low-income people with diabetes.

A 2018 report by the US Department of Agriculture (USDA) Economic Research Service (ERS) found that 11.8% of households in the United States were food insecure during at least part of 2017, meaning "they lacked access to enough food for an active, healthy life for all household members." The number is down slightly from 12.3% in 2016 and from a high of 14.9% in 2011.

Not long ago, food insecurity in the United States was thought of mainly in terms of "food deserts," which were based largely on a measure of a person's geographical distance from places that sold affordable, healthy food. The US Department of Agriculture came out with a detailed food desert locator, which was widely publicized.

Once the "food desert" term was coined, it took off, because it resonated with popular thinking that food insecurity happened when there weren't enough nearby grocery stores, Hilary Seligman, MD, MAS, associate professor of medicine at University of California San Francisco, told Medscape Medical News. The answer, therefore, was thought to be build more grocery stores. Tax breaks and incentives followed.

"The food desert literature was followed by massive efforts to put grocery stores mostly into African American neighborhoods, because that's where the food desert 'problem' was the biggest," she said. "What happened in most cases was that the grocery store failed or the market closed for lack of business."

Seligman explained that in a market economy, if all it took for people to start buying healthy food was having a closer grocery, companies would quickly answer that demand by building a grocery, without needing tax incentives.

But the problem, she said, is there's not enough money in many communities to afford the groceries or transportation to the sites.

Opening a Grocery Store May Not Help

Alyssa Moran, ScD, MPH, RD, assistant professor at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, told Medscape Medical News that her research team evaluated the effects of government subsidies in the Bronx, New York City.

In an earlier study, they collected data from adults in a low-income food desert about availability of foods in healthy and unhealthy food categories and surveyed the families on what they were consuming.

They compared findings 1 year before and 1 year after a supermarket was introduced. They also collected data from a control neighborhood in the Bronx with similar demographics that did not have a new store opening.

"We found that after a year, there was no effect of the new supermarket on healthy food availability or overall quality of a child's diet," Moran said.

"There have been several other studies that have found similar outcomes, so there's some indication that introducing the new supermarket may improve perceptions of healthy food access, but generally these studies find that adding a supermarket to a neighborhood doesn't really impact diet or obesity," she said.

Innovative Strategies

That kind of data convinced Seligman to try a different approach, and she founded EatSF.

Under EatSF, people identified as food insecure by community organization partners get $10 vouchers each week for roughly 6 months to use for fruit and vegetables at places they already shop — grocery stories, corner stores, or farmers markets in the EatSF network.

"Not surprisingly, what happens when you create that demand and allow for the money to saturate low-income neighborhoods, the stores start stocking a better quantity and quality of fruits and vegetables in response because it makes economic sense," she said.

Seligman said the city and county have enthusiastically invested in the program, as have public and private contributors.

"We service almost every low-income pregnant woman in the city as well as food-insecure people, particularly if they are at risk for chronic disease. We do that by partnering with community-based organizations all over the city," she said.

Her group is now piloting programs in Los Angeles and Boulder, Colorado. Outside San Francisco, the program is known as Vouchers for Veggies.

However, the program does not remove the transportation challenge, she acknowledged.

Addressing the Transportation Barrier

Some other recent strategies for bridging the gaps in food access include delivery models that bring food to homes or bring people to grocery stores.

Last January, the rideshare company Lyft piloted a grocery access program in Washington, DC, providing thousands of $2.50 rides to grocery stores for low-income local families.

Families with children enrolled at seven participating elementary schools received 50 flat-rate $2.50 Lyft rides for travel to and from four area grocery stores.

A spokeswoman told Medscape Medical News that results from the pilot are not yet available, but "realizing the positive impact the program can have," the program is being expanded to more than a dozen cities in North America this year.

Local partners helped Lyft identify families in need of the lower-cost rides, the spokeswoman said.

Low-Cost Delivery in Select ZIP Codes

Instead of bringing people to the food, the Blue Cross Blue Shield (BCBS) Institute, an Illinois benefit corporation and independent licensee of the Blue Cross and Blue Shield Association, is bringing the food to people in parts of Chicago with a program called foodQ.

Under the program, people who subscribe to the service for $10 a month get $5 healthy meals delivered with no delivery fee. Meals can also be purchased individually for $10 each plus delivery fee. The model strongly encourages subscriptions with the thought that high volume can keep prices low. Anyone in the 28 ZIP codes that are part of the program can participate. They don't have to have BCBS coverage.

"We thought it was the right thing to do for the community as a whole," Trent Haywood, MD, JD, president of the Blue Cross Blue Shield Institute, told Medscape Medical News.

Haywood said that in the program's first 5 months, they have seen a 94% retention rate on subscriptions.

Results are expected next from Dallas, where deliveries to 15 ZIP codes began this summer. Deliveries are expected to start in Philadelphia and Birmingham, Alabama, next year, Haywood said.

"It's hard to address diabetes and obesity without addressing the needs of the communities," he said. "While I can do a lot of things with a pad in writing for medication, the new prescription is around nutrition and fitness."

At the end of the year, BCBS hopes to have a better idea as to whether they see fewer hospital admissions and emergency department visits in the areas foodQ serves.

Essential to the program, Haywood said, is involving community members in taste tests because food preferences are highly variable by region.

Fresh Food Farmacy

At Geisinger Health System in Pennsylvania, the Fresh Food Farmacy, launched in 2016, is geared toward addressing the overlapping concerns of food insecurity and diabetes.

Maria Welch, MPH, a senior wellness specialist at Geisinger, told Medscape Medical News they looked for places where they could set up a food market within the health system.

They started in a rural area at Shamokin Area Community Hospital, a campus of Geisinger Medical Center, then spread to a pilot in the urban area of Scranton and are expanding to another rural site in Lewistown, Pennsylvania, with the hope of building sustainable models.

People aged 18 years or older identified as food insecure with type 2 diabetes are enrolled in the program. The Fresh Food Farmacy allows them to pick up free bags of fruits, vegetables, whole grains, and lean proteins, provided mostly by food bank partners. Those enrolled in the program are also connected with a care team, which includes a wellness associate, pantry manager, nurse health manager, registered dietitian, and community health assistant.

"We provide enough for the patient and the entire household. We believe that it's not just the patient. We're feeding the entire household so everyone can be healthy and benefit," Welch said.

In Shamokin, Welch said, Geisinger is providing 10 meals a week for families of 200 patients, so about 600 people per week.

The program is supported by foundation grants, private donors, and other philanthropy. Welch said it has already shown clinical results.

"So far we have seen an average reduction of two points for [A1c] for the Fresh Food Farmacy patients. We're also seeing improvements in glucose and cholesterol," she said.

In an interview last fall, then-CEO of Geisinger David Feinberg, MD, said, "To get US Food and Drug Administration (FDA) approval [for a diabetes medication], you must decrease hemoglobin A1c by 1 percentage point; we would say that kale and quinoa decrease it 2.5 points, because that's what we've seen on average."

Movement Toward Large Interventions in Small Areas

The biggest changes in food security will come when multiple barriers can be addressed at once, UCSF's Seligman said.

She compared the challenge to smoking cessation.

"Smoking rates plummeted when we were able to change cultural norms, provide medications, change laws and policies, make smoke-free housing. Once you have all of those things together, you can have a transformative change in the environment," she said.

Notably, Seligman said, that took both public and private partners stepping up and addressing part of the problem.

She said there is movement in addressing food insecurity toward place-based initiatives, where instead of small interventions spread across a broad area, more comprehensive interventions are concentrated in a several-block area to eliminate all the reasons that keep people from a healthy diet.

"If you're not fixing them all at once, people have too many barriers to make a behavior change," Seligman said.

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