In 2018, an estimated 1 in 9 Americans couldn’t afford enough food to lead active, healthy lives. The COVID-19 pandemic has doubled those numbers. To cope, families often rely on low-cost foods which tend to be unhealthy and exacerbate obesity, diabetes, and hypertension. Worse, those chronic conditions are associated with higher numbers of COVID-19 deaths.
The Food for Health Equity Lab brings together epidemiologists, biostatisticians, physicians, and leaders from Stanford University, ALL IN Alameda County, the Community Health Center Network, Dig Deep Farms, Open Source Wellness, and the Gretchen Swanson Center for Nutrition. As a team, they are working to generate evidence--about how nutritious food and fresh vegetables can reduce chronic disease--that community health centers can use to improve people’s nutrition, health, and well-being. They are one of six teams to receive start-up funding from Stanford Impact Labs for 2021-2023.
Steven Chen, chief medical officer at ALL IN Alameda County, Amy Lazarus Yaroch, Executive Director of the Gretchen Swanson Center for Nutrition, and Lisa Goldman Rosas, assistant professor at Stanford University’s department of epidemiology and population health and the department of medicine, describe the team’s work with farmers, community leaders, and researchers to test a “food as medicine” intervention.
What is the social problem you are working on?
LISA GOLDMAN ROSAS (Stanford): We are working to increase access to healthy, nutritious food for more people, and reduce the effects of chronic diseases on their lives. Lack of access to health food, or food insecurity, has always disproportionately affected families living in poverty, those in under-resourced communities, and communities of color. During the COVID-19 pandemic, food insecurity doubled and in some communities tripled affecting close to 40 million households in the United States. Food insecurity can make it extremely difficult to prevent and manage chronic disease. This is because a healthy diet is the cornerstone of effective prevention and management of chronic disease. This is even more important during the COVID-19 pandemic as these same chronic conditions increase the risk of poor outcomes from COVID-19.
STEVEN CHEN (ALL IN Alameda County): Alameda County’s Food as Medicine initiative is using a health equity approach to tackle social determinants of health (with a focus on food insecurity and social isolation), chronic disease treatment and reversal, environmental issues through regenerative farming, and public safety. The nexus of this work occurs at community-based health care centers known as Federally Qualified Health Centers, like ALL IN Alameda County, that provide primary care services in underserved areas.
Patients hear, “You need to eat better, you need to exercise more, you need to reduce your stress,” because these are the things that have the biggest impact on health, but our healthcare system has no structure or support for following up on those prescriptions for low-income communities. Additionally, healthcare practitioners have minimal training on how to use food and exercise to treat, prevent, and reverse chronic disease. Further, social determinants of health, like food insecurity, poor diet, and social isolation, have major impacts on people's health and emotional wellbeing, especially in low-income communities.
Alameda County’s Food as Medicine initiative combines prescriptions for healthy food with behavioral support through a group medical visit. Healthy foods, and fruit and vegetables in particular, are important for the prevention and management of chronic disease. They function in many ways like a preventive medicine, because if you take them daily, they will prevent the onset of nutrition-related disease. The behavioral group support reduces social isolation and exposes patients to physical activity; nutrition education; mindfulness and stress reduction; and health coaching. Finally, Food as Medicine’s approach to training and integrating the program into the electronic health record makes it easy for physicians and frontline healthcare staff at primary care clinics to prescribe and deliver the Food as Medicine intervention.
We believe that we can address the social determinants of health through data, advocacy and policy work to fundamentally change the practice of medicine, while improving health outcomes and reducing healthcare costs. One policy impact we hope to achieve will be that medically supportive foods and behavioral/nutritional support services will become “covered benefits” by health plans.
AMY LAZARUS YAROCH (Gretchen Swanson Center for Nutrition): The social problem of food insecurity and poor health outcomes among low-income populations is of elevated concern given the coronavirus pandemic. The pandemic has led to a spike in food insecurity, especially among the most vulnerable populations. Produce prescription projects providing low-income participants with elevated risk for chronic disease increased spending power for fruits and vegetables.
What will the start-up lab funding and team approach help you do?
LISA GOLDMAN ROSAS (Stanford): The start-up lab funding lets us conduct research that is community-driven. Our research is different because community partners are integrally involved from the very beginning--defining the research question, designing the study, analyzing data, and disseminating results. For our examination of the effectiveness of our “Food as Medicine” intervention, the funding will enable us to include a control group for a more rigorous evaluation. In addition, we will be able to include a mixed methods analysis of the potential for implementation and dissemination across diverse geographic and demographic groups.
AMY LAZARUS YAROCH (Gretchen Swanson Center for Nutrition):The start-up lab funding fills an important gap in our research by dissecting program implementation to understand “what works” and under “what conditions.”
STEVEN CHEN (ALL IN Alameda County): Working with a Stanford University research team will support Alameda County to engage in research and evaluation critical to the long-term success of the ALL IN Alameda County’s Food as Medicine initiative. Our normal approach would be focused solely on programmatic and operational execution of the program without rigorous evaluation. By partnering with Stanford, the data and analysis generated by this study will support us to improve our services, raise awareness about the importance of nutritious food within clinical settings, and support policy and systems change in ways that would not otherwise be feasible.
Q. What are you most excited about with this work?
LISA GOLDMAN ROSAS (Stanford): I am most excited to provide data to our partners that will impact food insecurity policies in primary care settings. I’m hopeful that process, and our partnership, will improve treatment of food insecurity and management of chronic disease for more people.
AMY LAZARUS YAROCH (Gretchen Swanson Center for Nutrition): We are most excited to learn how produce prescription projects work and under what conditions. We’re eager to translate and share what we learn so that we, and others, can reduce the burden of chronic disease and food insecurity.
STEVEN CHEN (ALL IN Alameda County): ALL IN Alameda County’s Food as Medicine initiative looks forward to working with Stanford to provide critical research, evaluation and feedback to ensure that the work we are doing supports the needs of Alameda County residents experiencing food insecurity, social isolation, and living with chronic conditions such as diabetes, hypertension, depression, and anxiety. We are excited to see the impact of sourcing Food as Medicine from regeneratively grown food and seeing the impact on the environment, and the impact on public safety as we increase green economy jobs. Finally, we are excited to see the practice transformation that can occur at Federally Qualified Health Centers by this model.