hello everyone um my name is sen sagum verulam I am a general pediatrician Health Services researcher at the University of Pennsylvania in the Children's Hospital of Philadelphia and I'm going to be speaking with you all today about the relationship between food equity and health and the role that Physicians and Healthcare Systems play in this space I have no Financial relationships or conflicts of interest to disclose so just to give you an overview of our discussion today I'm going to start by introducing myself and what led me to this work I'll then go over kind of key Concepts around food security nutrition security food equity and food Justice and then I will discuss the relationship between food and health and what we in the healthc care space uh can do so to start I mentioned that I'm a general pediatrician this photo is of the Tuesday farmers market in Berkeley California it's where I shopped every day when I was a resident at Children's Hospital Oakland during the course of my pediatric residency I had the opportunity to care for many kids and one patient in particular really crystallized what I would then decide to spend the rest of my career focusing on his name was Jaden um I had been been following him as his pediatrician from the time he was 2 years old and by the time I was in my third year of residency he was five and he came in for his physical and in that intervening year he had gone from being of a healthy normal weight to being obese and so I talked to his mom as I had been trained to do about all of his habits um his eating habits his exercise habits how much time he was spending in front of a screen his sleep s and we set a couple of goals of things that that she could work on at the end of the visit when I met her in the waiting room with her prescriptions this was before electronic prescriptions existed um she asked me she said Doctor can you tell me about your daily routine you know what do you eat every day and that was one of the questions that we always ask kids and families during a well visit and it was really the first time in my career that a parent had asked me that same question and so as I proceeded to answer her and bear in mind this is a busy pediatric Primary Care Clinic in the heart of Oakland our waiting room was always bustling and loud and I thought about whether I needed to bring her back into an exam room but since I was talking about myself I thought it was okay to do that in the waiting room and so as I started to talk about my morning remember I was a resident so I didn't have much time um you know I started to tell her I get up in the morning I put my oatmeal in the microwave while I'm brushing my teeth and then I might add some fruit to it and eat and then run out the door as I was telling her this within about 15 or 30 seconds the waiting room was silent you could hear a pin drop and every parent with an earshot was listening to what I had to say that was a watershed moment for me it was a moment when I realized that even though every parent I've ever met wants to nourish their children sometimes the path to do that is difficult or unclear um and so I was fortunate enough then to come here to Philadelphia to continue my training as a researcher and really Embark upon a career trying to uplift kids and families um towards being able to eat everything that they want to and ensuring that nutritious fresh healthy foods are available to everyone in our country so moving to some key Concepts food insecurity you've probably heard this term food insecurity unfortunately is highly prevalent and has become even more prevalent after the covid-19 pandemic today food insecurity impacts 17.5% of us households with children um and locally here in Philadelphia 25% of children approximately are thought to live in food insecure households so even higher than the national average and in Philadelphia that amounts to 90,000 kids so enough to fill our football stadium unfortunately it's sobering to think about what is food security what do me what do we mean when we talk about food security and food insecurity um and so this definition um characterizes food security as meaning that all people at all times have physical social and economic access to sufficient safe and nutrition ious food that meets their food preferences and their dietary needs for an active and healthy life um this is from the wh the USDA the United States Department of Agriculture defines food insecurity as the lack of consistent access to enough food for an active and healthy life which includes the limited or uncertain availability of nutritionally adequate or safe foods as well as the limited or uncertain ability to acquire acceptable foods and socially accept ways food insecurity has Myriad negative associations with health and as a pediatrician I think a lot about child health in particular um including developmental delay School difficulties anemia obesity and all of the nutrition related chronic diseases that we all hear about seemingly all the time these days including cardiovascular disease and diabetes in the the last few years the USDA has moved from focusing on food in security to really focusing on nutrition security and what does this mean the concepts are the same but nutrition security really um emphasizes the important of not just ensuring that people have access to food but ensuring that that food is of high quality um and will allow them to eat a nourishing and nutritious diet nutrition security as a concept also really emphasizes Equity um and ensuring that all people in our country have access to nutritious Foods so I'm going to move now to talk about food equity and the related concept of food Justice this is a figure that many of you have probably seen in different contexts that really delineates the difference between equality and inequality and then what do we mean when we say equity and and what does justice mean how are these Concepts distinct so starting with inequality you can see that the child on the right has no idea how they're even going to reach that one or two little apples on the tree near them right the child on the left has apples literally falling on them and so the the child on the right um just has a much lower likelihood of ever being able to get an Apple this is inherently unequal on moving on to what we mean by equality um we can add ladders for these kids so that they can reach the same height but the tree is tilted in One Direction and still one side of the tree has fewer apples and so while both both kids in this picture have an equal chance of standing at the top of the ladder it doesn't mean that they have an equal chance of getting an apple when we talk about equity and food Equity what we mean there is that both kids have the chance of reaching the tree right and so both kids here um have ladders but the ladder on the right is taller it needs to be to get to the tree but it's still not an equitable system there are still fewer apples on one side of the tree when we get to Justice the tree stands straight and tall and there are apples throughout the tree and an equal number of apples everywhere on the tree and so this is a just system um represents really a just system where both kids can have the same height of ladders to reach the tree and what we mean by the tree is the same for both kids and so this really um I think helps to illustrate the concepts of food equity and food justice so food Equity um again contrasting with with nutrition security food Equity um does emphasize access to nutritious and affordable food for everyone but food Equity also emphasizes that that food should be culturally appropriate when we move to the concept of food Justice um food Justice incorporates really the entire food system and so think about the well-being and safety of food and Farm Workers for example and food Justice really aims to address structural inequities in the food System including racism that have led to an unjust food system and just a note on going back to food Equity that really food Equity is still very much at the individual level and kind of more focused on that indivi individual even households maybe even local community level where food Justice is a much broader concept where we're thinking about the entire food system the food system is very very complicated um so there's a lot going on on this slide and you're not meant to kind of dive into every every piece of this unless you're really interested but this figure is from the United Nations um and really you know in the healthc care space we are focusing on this this green box right here right we're focusing on the individual we're focusing on people's diets um we're focusing on nutrition nutrition and health um and rarely um do we get to zoom out beyond that uh beyond that point to really think about the entire system and certainly not in the individual um Healthcare Providers interactions with patients but but all of this matter matters and that's really what I want you to take away from this slide is that the entire system matters and impacts individual and family level behavior and health so I'm going to move now to really hone in on the relationship between food and health and unfortunately there are really significant disparities in in lifestyle and diet related chronic disease prevalence um particularly with cardi metabolic disease and these are related to food security status and so there's a lot going on in this figure I'm just going to walk you all through it so each graph is looking at um a different kind of Health indicator and how prevalent um that condition is amongst um non-hispanic white populations in the United States non-h Hispanic black populations Hispanic populations and then other um races as and ethnicities and these racial and ethnic designations um were taken from the categories that are put forth um within the national health and nutrition examination survey um which is a nationwide survey conducted by um the national Center for Health statistics which is a part of it's a it's a federally run program um and so just to kind of clarify um how these racial and ethnic categories kind of came about and so this study um analyze those data um from the early 2000s all the way until 2018 to look at disease prevalence and kind of the first thing that jumps out as me as I as I look across obesity hypertension coronary heart disease and diabetes and this is also only amongst adults not including kids is that all of these conditions are more prevalent among racial and ethnic minority populations meaning Black and Hispanic populations that's one thing um the second is you can see moving from left to right within each category so the blue is fully food secure meaning full access to nourishing food and then as you move to the right the orange the gray the yellow um these um are representing groups that are more and more food insecure with the yellow group being the most food insecure to the point where they're experiencing hunger regularly and you can see again that in almost you know every single one of these that the more food and secure you are regardless of your race or ethnicity the more likely you are to have cardiometabolic disease so food in security and food security and the related concept of nutrition security that we talked about are are really important in terms of determining disease risk disease prevalence Health inequities and ultimately hopefully informing our efforts to ensure Health Equity in our country so what drives the way people eat um at the individual level these are the steps that we all have to take every day when we eat something so first you have to plan what you're going to eat and then you have to go get it you have to you might have to make it depending on what you decide to get um prepare it and then finally we eat that pathway though is um is driven by our beliefs our motivations our ability to engage in Preparatory action um meaning are you know are we able to turn that motivation into a behavior that behavior ultimately of healthy eating and all of this is further informed by our context so this figure shows you the socio eological model of Health um and again everything I do is child um child and family focused and so you see that represented here that health or a child's health an adult's health is really going to contextualize within their behavior their personality for everyone child and adult alike um our our home environment for kids their parents are going to be really important the family environment and context are incredibly important and zooming out even further from there what where do we spend our days kids might be in child care or in school adults might be continuing their education like all of you or working um and so those contexts where we spend our most of our waking hours are really important and inform our health health and well-being and finally our community context matters especially when it comes to food and food access um this could mean things like what grocery stores are available but also the broader Community right so thinking about state level policy for example or federal policy and the way that that food system interplays with what's happening in the local community all of these impact the pathways that I just showed you in terms of individual and family level behaviors around food at the policy level on the federal level the United States Farm Bill funds all of our federal federal programs around nutrition the farm bill is renewed every 5 years the last farm bill was in 2018 um meaning the current farm bill is um currently under debate in Congress the last Farm Bill included 428 billion dollar of mandatory spending and almost an equal amount of discretionary spending most of that $326 billion doar of mandatory spending was on nutrition programs and nutrition programs include things like Snap or the supplemental nutrition assistance program um as well as Wick School meals senior vouchers um there are many um programs that fall under that Federal nutrition program umbrella but snap is by far the largest so what is snap snap also used to be called food stamps um it is what it says it is right it is nutrition assistance um for people that are experiencing poverty to qualify for this program a household's gross annual income has to be less than 130% of the federal poverty level um this equates to about $2,841 a month for a family of four that number will vary depending on geography and in terms of how much money that affords each person in the family per meal it's on average .92 per person per meal and that number was increased in 2021 to better reflect how much it costs to follow our current dietary guidelines snap covers food for the household including fruits vegetables proteins Dairy bread um other foods like snack foods any non-alcoholic beverages it does not cover um alcohol olc beverages supplements live animals um foods that are hot at the point of sale and other items that you see listed here the farm bill also provides funding for the special supplemental nutrition program for women infants and children or Wick Wick is intended to support pregnant and postpartum women as well as infants and children up to the age of five recognizing how important important appropriate nutrition is during that critical developmental window of Early Childhood families who have incomes at less than 185% of the federal poverty level are eligible um as well as pregnant women women up to 6 months to a year postpartum depending on whether they're breastfeeding or not um and infants and kids as I said up to age five the farm bill also supports the Gus shoeer nutrition incentive program or Gus niip which provides support for nutrition incentives these are point of purchase nutrition um incentives for people who are using snap EBT cards typically if they're being used to purchase fresh fruits and vegetables families will get either an immediate um subsidy or money back um in various forms and I'm going to talk about an example of this program in Philadelphia shortly um but money back that can then be used in the future for fresh fruits and vegetables produce prescriptions are kind of even more tored more specific um these are vouchers provided typically by healthc care providers or Health Care Systems to families and kids and individuals experiencing diet related chronic disease or who are at risk for poor nutrition so there the farm bill has kind of various levers in which we try to support um everyone in our country to be able to eat a nourishing diet um produce prescriptions I sort of just talked about kind of the flow of how they work um this figure kind of shows that really nicely some produce prescription programs include an educational component ours does and I'm going to just talk about that in a little bit as an example of one program so what should we do what can we do as a physician and for those of you who go on to become Physicians um we are bound by this oath the hipocratico and this is not the whole hypocracy but there's you know a key um point in this that I want to draw out which is that we have all taken an oath to prevent disease whenever we can for prevention is preferable to cure so this is part of what our calling is regardless of our specialty disease prevention is at the core of being a physician the Biden Administration um really has shown a spotlight on the importance of nutrition and health in the context of many folks in our country unfortunately improving hunger um these five pillars were called out in the document that is pictured here the focus of a conference of convening that occurred in 2022 and so that um convening in 2022 was a moment that was supposed to Galvanize people across the country community members institutions um academics researchers anyone working in or interested in this space um to really coas around these five pillars and um and the administration essentially wanted to emphasize how important nutrition is for health um since then on a federal level there have been efforts to coordinate um various efforts within government to really support these pillars um and it's a real opportunity um kind of the most promising opportunity from a policy perspective that I've seen in my career um with just a real focus on this space so what is the physician's role um in the healthcare context we conduct screening and preventive care um in the Pediatric context we screen for food insecurity at every Well Visit um and we do that so that we can talk about it with families and try to support them make sure that they are um enrolled in any benefits programs that they might be eligible for um and let them know about local programs that might provide additional support in Pediatrics we discuss nutrition throughout the life course it's a part of every Well Visit we see how kids are growing we make sure they're growing in a healthy way and if they're not um we talk to families about how we can support them with that motivational interviewing is really really important I cannot emphasize this enough enough a person a parent a child an adolescent whomever you're speaking to and even if you're not a healthcare provider anytime you're talking to someone about changing their habits or their behaviors they have to be ready to do that and so that's really the first question that needs to be asked is where a person is in terms of their Readiness and then depending on how ready they are then we can support them in setting goals that are are small attainable goals um and really continuing then to coach them as Physicians through that process I talked about some of the supports that we offer patients who are food insecure like benefits enrollment and Community Resources and I want to talk now about a couple of community- engaged programs that really aim to support nutrition security that we have developed and tested um here in Philadelphia at the Children's Hospital I'm going to talk about the design of both these programs home plate and food Buck RX um you know some of the Assets in terms of how we were able to do this our strengths and why we were able to kind of get this off the ground as well as challenges we faced and where we Invision going um for all of you who are at the start of your careers I really hope that this can serve as an example of the way um Community organizations and Academia can partner together and I think you know the lessons are Salient not only for those working in the health care space but for anyone interested in this space that that wants to partner with others which I think is is critical given the magnitude of these problems partnership across sectors is critically important we cannot solve these big problems without that partnership and so I hope that some of the lessons that I'm going to highlight will inform your efforts regardless of what career you choose to go into so the objective of our work with home plate and food Buck RX was to empower low-income families with young children to prepare and eat nutritious Foods by increasing both food literacy through home plate as well as access to fresh produce through food Buck RX so what does Home Plate do home plate in is intended to really act on this Pathway to support families with food planning food food procurement or shopping food preparation and ultimately getting their kids and we worked with families who have young kids so getting kids to eat the food that is offered and prepared at home is its own Challenge and Home Plate focuses on all of this home plate um is not intended to be sort of a really dactic heavy intervention um it's meant to bring families together create connection and Community um and to really have fun with food and cooking and eating um and in that way to inspire families to you know attain the changes that they hope to do um this quote is from a randomized control trial that we did looking at the impact of home plate on diet um in the context of that study we did um systematically interviewed conducted semi structured interviews with all of our participants to understand um their thoughts about the the interven ion of Home Plate and how it impacted them and their families and so one mom said um when asked about her experience with home plate she said here's a recipe make something so I think that was it was encouraging it was it made it seem like it was something that was attainable it helped me cook at home because it's when you don't have time and you're busy with things and you have the choices it's hard to take the hard way um and this photo is is from one of our our home plate classes um and you see that people are are enjoying their time together um this intervention was developed in very close partnership with Early Head Start here in Philadelphia um in partnership with their staff but most importantly their families we spent a lot of time in the community trying to understand what kind of intervention kind of program people wanted um and then creating that so it's a six weeklong program we have a loose framework of learning objectives for each session um sessions are typically once a week we used to do them in person and now we do them virtually um that happened because of the pandemic um but it also has really been a joy to have people um cook together from their own kitchens um every week There's a theme and the goal is to make sure that we create a space where families can come together and talk about that theme talk about what their own goals are what they need to learn and really share expertise and knowledge with each other um so for instance there's a week that's focused on fruits and vegetables um and I'll never forget um the first time we ever did these classes one mom asked us well she asked her peers really the other parents in the group how do you tell the difference between greens that you cook and greens that you don't cook and I you know that example always stuck with me because that's not something I would have thought to teach to um it's something that was really really important for her to know in order to be able to incorporate more greens into her her life and her children's lives um and she was able to be in an environment where she felt comfortable asking that question and and you know could get feedback and coaching and teaching from the other parents who were there this is a trauma informed intervention meaning that um we really focus on peer support creating a trusting and empowering environment and it was made created that way um because this intervention was really created by parents for parents I mentioned that we conducted a randomized control trial of the intervention where we did see um some promising impacts on diet and so that's you know when we had just finished that trial when the pandemic hit um and we were entering into a partnership with the food trust which is um a nonprofit organization here in Philadelphia focused on on food and food policy we wanted to work with the food trust um to be able to incorporate additional support for our families to be able to get fresh fruits and vegetables in their community and this was because in the randomized control trial we saw um signal in terms of improvements for participants in saturated fat intake and added sugar intake but we didn't see any changes in fruit and vegetable intake and so we knew that you know part of that that is a harder um eating Behavior to change um for a variety of reasons and one reason for families experiencing poverty is that it might not be very easy to get fruits and vegetables in their neighborhood and so the food trust really works to make fruits and vegetables available in every community in this city um produce prescriptions are the one of the ways they do that and that's the food Buck RX program so if you recall these are vouchers provided by healthc care providers to their patients um they come in $10 increments and there are many many many Redemption locations throughout the city including large grocery stores farmers markets and small neighborhood stores and so we um since the start of the pandemic have combined produce prescriptions or food bus RX with home plate and we're really looking at the impact on children and adults diet quality um and looking at that in the context of two different studies um one is a randomized trial um that's a three arm randomized trial where we have one group getting food Buck RX only the second group is getting food Buck RX with an asynchronous version of homep plate called hom plate light um that is essentially just access to um pictorial handouts and videos that um go through the curriculum that we've designed for home plate and then the third arm is getting all the interventions so they get uh foodb RX home plate light and also live synchronous home plate which is what I was describing to you earlier um we are also conducting um a dissemination implementation evaluation so really just rolling out these programs see how they operationalize for families in the primary care context and also in the daycare context we've partnered with early care and education um early care and education centers here in Philadelphia um and I mentioned that we are looking at um diet quality as one of our outcomes but we're also looking at Food security um and together when we're looking at Food insecurity um and diet quality together that allows us to really have a picture of how these interventions are impacting nutrition security um our population includes young children um five and under and they're caregivers um and we are trying to enroll um kids and Families who are at high risk for poor nutrition either at the individual level um or at the community level based on where their Primary Care Clinic or daycare site is located um we have recruited families for these studies from our primary care clinics here at chop as well as Early Head Start um and we're measuring diet quality in a couple of different ways one is through um a diet survey where people um essentially tell us everything they ate and drink the preceding day that's the ASA 24 um we're also partnering with the pen Center for nutritional science and medicine um to look at um urine metabolites um and that indicate the the quality of a person's diet and then food security we're measuring through an 18 item validated survey from the United States Department of Agriculture so how did we get all of these Partnerships to work so you know one of the keys is making sure that all of the organizations that are partnering together have overlapping and synergistic missions um and so you know you can see here that you know if you look at my lab um the food trust pensam Early Head Start everyone has a focus on Equity so really trying to create programming and better health for everyone that they touch um Early Head Start is really focused on empowerment um as is the food trust and my lab um and and pens Sam is is really thinking very critically and carefully about um population health and nutrition and so our our missions were synergistic enough um that we had a foundation to really um embark on and then weather the challenges of this partnership the timing has to be right um so the food trust um you know I mentioned is based here in Philadelphia they are our local gnip grantee through the USDA um they have many HealthCare Partners and seek to partner with Healthcare organizations we are one of their Partners um and then you know for my lab and where we were with the research it so happened that when the food trust was applying for gnip funding for produce prescriptions that coincided with the timing of um of really completing the home plate randomized control trial where we showed that we had POS positive positive impacts on self-efficacy related to cooking and eating healthy that families told us they were able to set specific strategies for cooking healthier meals after participating in the intervention um and I mentioned that we showed some impact on saturated fat and added sugar intake um but needed to focus on fruit and vegetable intake um and also the RCT showed us that those families who were at higher risk to start stood to benefit more from the interventions and that's why we have a really focused on families with risk for poor nutrition or food insecurity since then you need money um to get to get a partnership off the ground um you know we uh started this work um together in 2020 in the spring of 2020 which was a really difficult time we had a little bit of funding to do some pilot grants and then the whole world changed and we had to kind of build the plane as we were flying it so we had um as I mentioned some funding but then we had to seek additional funding to really support the work and the vision and we were able to to do that together and so for all of you if you are thinking about starting something in your own Community I think it's really critical to get Buy in from stakeholders local community stakeholders um as well as those um who are in in the funding space um locally or within your Institution who might be able to to support the work and it's it's really important to bring those stakeholders in early so they can um so that the the work that you're doing kind of is a shared Vision that everyone is excited about um turning two big ships together so so I always I always think of um you know really the Titanic right so we all know the story of the Titanic it was too big it couldn't turn in time and the rest is history um so the Children's Hospital of Philadelphia is a huge organization since I made these slides actually I think now we're at 16,000 employees up from 15,000 we're the oldest Children's Hospital in the United States change does not come easily here um although it is an amazing environment to um incubate Innovations and then eventually scale them and the food trust also is a really storyed organization a national leader in food policy and advocacy um and they have a long history of leading Grassroots food access work um and so we had to you know we had individuals within both of these organizations that were really excited about this partnership and then what we had to do is bring our stakeholders in which I started to talk about um on the earlier slide bring in stakeholders get their Buy in um and then that's what allowed us um to be able to operationalize the vision that we had in terms of partnering together building authentic relationships is critical um there has to be open communication and the ability to solve problems together um empathy is key empathy for oneself empathy for one's colleagues um empathy for the communities that we're all working to serve um you have to invest time to create authentic relationships and Partnerships and you have to be really patient um and be able to to openly share um the challenges that are are coming up and then troubleshoot and brainstorm together of how to overcome those challenges um so we have um enrolled and had 90 families go through our programming and the randomized trial in the dissemination and implementation work with primary care clinics and in daycare centers in Philadelphia we've had 200 families participate um we are in the midst of analyzing those data um and spoiler alert it does look like um we had some real positive impacts on nutrition security for all those who participated um and so we are in the process of really scaling up this work um here at the Children's Hospital of Philadelphia and we're really really excited um to be able to continue these Partnerships um and hopefully share the lessons that we've learned with others um locally and across the country who are trying to do similar work so in conclusion what I really want you to take away is that food equity and food Justice are critical for Health Equity we can't prevent diet related disease without thinking about the larger systems that um that lead to those problems in as physicians in health care we can do a great deal and so can our community members and we can do even more if we partner together partner across sectors and really work together to create a more just Society so I want to thank all of you for listening as well as the many Community Partners and collaborators and mentors and students um who have been a part of this work um over the past 15 years I am eternally grateful it's a team effort um and I'm happy to be a resource for any of you if you if you have ideas and want to reach out um always happy to support the work you're doing in your own Community thank you very much