Building Food Security Street by Street

foodbank-healthy-neighborhoods-logo-master-copy

 

Hunger is always perceived as a hyper-local issue. Smaller scale cash donors within a city or town in your service area are often very concerned that their dollars are spent for food within that community. They don’t want it to go to those folks fifty miles away who might as well be in a whole other universe. We might consider this as a parochial attitude and believe that these people don’t see the bigger picture like we do.

But, what if they’re right?

What if we’re so obsessed with total impact / poundage / meal gaps and systemic change that we can’t focus on the type of grass roots neighborhood level work which can be truly successful and sustainable?

Laying our own astroturf has been easier but this stuff grows.
Laying our own astroturf has been easier but this stuff grows!

That’s someone else’s job, right? A partner agency who can get into the weeds while we keep that big food machine humming. But we used to say that about a lot of things, like SNAP outreach or nutrition education. I’ve also always been concerned that we’re accidentally creating a ‘new norm’ of food security in that people will get increasingly used to saying: “Yes, of course I’m food secure, because I can go to this pantry on this day and then that pantry on the other day.”

No kind of security
No kind of security.

In Santa Barbara, we are ready to pilot ‘Healthy Neighborhood’ programs designed to be sustainable local solutions to food security and food literacy at the micro level. They represent the next step in the (occasionally painful) realization that we can’t make or keep a community food secure by only working with those who most need our services.

Ouch, what did I just say?

Do you think we have resources to just spray around? Unlike you, we’re not in ritzy Santa Barbara with sun and sand and aging movie stars. We live in the real world and we have to concentrate resources on those most in need.

Someone just out of the picture is filling in their SNAP application. We serve one in four of the population
Someone just out of the picture is filling in their SNAP application. We serve one in four of the population.

Yes, I get that perception, but we are a medium-sized food bank with a modest $4 million cash budget where cash is always tight. It would be easy for us to walk away from such an approach, but we can’t. Let me make clear that our food resources unquestionably go only to those who really need them. But educational and community building resources are going to have to be offered wider than that. Those that can pay will pay or subsidize others. While this creates short-term financial pain, it will also broaden and deepen the donor base and introduce new perceptions of the organization as a good for everyone in the community, not just those ‘disadvantaged others.’ (aka ‘the needy,’)

Consequently, Foodbank of Santa Barbara County’s Healthy Neighborhoods Initiative marks a major pivot in approach, transitioning our work in neighborhoods of high poverty and food insecurity from a client-based to a family-based model. This initiative is designed to bring together a whole neighborhood of families in the effort to build a resilient and nutritionally healthy community, where food and health become the focus for community engagement, education and economic development.

You don't have to build it for them to come. There's plenty of buildings sitting there.
You don’t have to build it for them to come. There’s plenty of buildings sitting there.

Each pilot will be based around key physical locations, operating as Community Food Access Centers, which are place-based, food-centric neighborhood revitalization efforts, uniting multiple educational, nutrition and community development functions. These centers will have a family-based focus. You may be familiar with The Stop in Toronto Canada. At this stage of the initiative’s evolution we don’t have the luxury of building one of these or utilizing a facility just for this purpose, so we have to make use of existing places with their own range of activities – community centers, schools etc.

Initially, the center will only operate one day a week, but it will be intensive. Food and age-appropriate education will be provided for the whole family to attend at a time convenient to them. Childcare and basic food literacy training will be provided for young children; culinary skills will be provided for teens. Education will be culturally as well as age appropriate.

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Though there is one day per week where education and services are focused, other satellite activities will happen at other times. There will be regular communication across a number of media and communication platforms to keep the neighborhood informed and involved in the effort. Centers in targeted neighborhoods will provide low-income families with a specific place to go, where people that you know and trust will be teaching and learning with you. The idea is to break the cycle of poverty and food insecurity by including all generations; they will also work to channel partner services in a more culturally-appropriate and culturally-tailored manner, in an environment in which families and neighborhoods feel comfortable coming together and learning with each other.

Slide24

Providing the life-blood of the Community Food Access Centers and supporting community involvement are neighborhood networks of volunteers – Nutrition Advocates – that provide  bi-lingual peer-to-peer education, empowering community members to improve their health. Food-related programs offer the “idea bridge” for others to provide skills and knowledge training.

Other elements of this strategy are:

Small Food Business Incubator – Encouraging entry into local food economy by providing business, food safety and marketing training to Nutrition Advocates and food entrepreneurs, and the opportunity to develop small businesses.

Food as Medicine Programs – Diabetes Education/ nutrition education/diabetes specific food support programs.

This approach builds on existing geographically local impact groups that we have been working on for the last couple of years and the relationships that have come out of them.

Collective impact projects come and go. Funding comes and goes. The idea here is to find a low-risk approach, because it involves empowering the community to help itself. Networks and relationships will grow, increasing community cohesiveness and requiring less outside stimulus.

Slide11

Ultimately, a neighborhood approach does not rely on the desire to help ‘others’ but on the practical need to help ‘each other,’ by living in a neighborhood where mutual support to obtain and keep good health reframes how people engage with each other. This is incredibly challenging to our ‘big’ way of operating, but it is also exciting, representing the opportunity for a much more inclusive and empowering approach to our work, and the opportunities for new approaches to how we fund that work.

I’ll let you know how we get on.

In the meantime, why don’t you consider taking a walk and building food security street by street.

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No More Band Aids – Strategies and Five Tactics for helping your clients long-term by evolving into a health-outcomes based organization

Are you sure this is the cure for food insecurity?
Are you sure this is the cure for food insecurity? Because my symptoms just started again.

Big Data is Coming for YOU

One day not too long from today, funding for organizations like ours will be heavily based on the social impact returns we can bring against the financial investment made. We will have to make our cost benefit pitch over what improvements in health can we bring. Who are the specific groups we will touch and what specific disease areas will we help to mitigate or eradicate? How much money can we save the City, County, State and Nation in healthcare costs? Over what period can we do it?

If we can put forward a persuasive argument, we will receive funding with the remit to deliver on our proposals. Our food and education programs and our demonstrated ability to link to a continuum of community support and empowerment for under-resourced individuals and families will help us make a strong case.

We will then have to evaluate and measure impacts and wrangle and present the kind of data that makes our current activities in this area seem equivalent to counting on our fingers.

It could be like Feeding America’s quadriannual Hunger Study – every day!

Before you wake up screaming in sweat-soaked sheets, we are not there yet. This may be a world that you don’t want to get to. However, it is coming, whether you like it or not and we need to position ourselves by our deeds to demonstrate the hugely beneficial public health impacts of food banks.

Join the crazy food bank health kick!
Join the crazy food bank health kick!

Sure, I am a nice guy who wants to help people be healthy and feel positive about what they can achieve in life for themselves, their families and their communities. But I also care about the long-term direction and viability of organizations and a network like ours. We need financial resources to do our work, and our march into the future is going to require mastery of juggling dual funding streams (charitable donations for food insecurity and provider service fee payments for health outcomes) to be able to survive over the coming decades.

From my cheap seat in the bleachers, hunger is no longer driving the national discussion in the way it did a few years ago. It is already viewed as a sub-component of poverty, which has morphed into the ‘real issue.’ The perception is now that the country has drifted in a situation where people find it incredibly difficult to improve their circumstances no matter how hard they work, no matter how much they take personal responsibility for their own situation.

lost my job

Partnership with other organizations nationwide and locally is the only way to begin to take on both situational and generational poverty. Feeding America’s fledgling Collaborating for Clients (C4C) initiative is a great step in this direction. Here is a download for some FAQ’s about this: Collaborating for Clients FAQ_1.27.2014[2]

The vital next step after that is ‘collaborating with clients’ to achieve the kind of sustainable transformations in local communities that will work long-term. The Federal government is not going to gallop in on an ethnically balanced white/brown/black horse and save the day. Those days are done. We have to help micro-communities connect and find their own solutions, and then turn around and use their own power and ability to work together to drive the national agenda from the bottom. I mean, what is the point of all this social networking crap unless we can get it to do something worthwhile, right?

Anyway, it’s clearly time for one of my pink happy pills to calm down, because all that is still a ways off and we want to help people be more nutritionally healthy right now.

And so, there is ‘preventative health’ which can be the second flank of a ‘pincer movement’ that enables us to come at the ingrained and complex problems of poverty from two different sides, utilizing different partners. Fighting poverty through job creation and community development is actually not enough in itself. If you improve people’s financial situation, you can make them food secure, but this doesn’t necessarily improve their health. However, if you work to help people improve their health, you give them skills (food literacy) that will be invaluable to them in times of scarcity or times of plenty.

Another quiet day at the Food Bank
Another quiet day at the Food Bank

I also think it is possible to steer the issue of poverty away from being a lightning rod for people’s knee-jerk political reactions and deep seated personal fears (oops, same thing) and into a more neutral territory where we treat the ravages of poverty as a public health issue that there can be broad consensus to rally around. That is a ways off, but I think it gives us somewhere to head for that is worth reaching for.

The Tactics

So that is the ‘why.’ What about the how? How can we engage with the current preventative healthcare framework and demonstrate our worth to be part of this fabric.

Below I lay out five different steps you can take. You can’t do all of these things at once (don’t tell my staff that, though), but achieving a win in any of these areas will give you some credibility and provide the foundation to broaden and deepen your health-related activities.

diabetes-article-10-11-2013

1. Diabetes is a great place to start:

Playing a part in diabetes care is one of the best initial possibilities for demonstrating the vital role we can play in community health. Obesity is much harder for us to prove the specific benefits of our role. (Even for us our food bank with 60% of our distributed product as fresh produce). Diabetes is much easier for us to demonstrate the success of our interventions.

For the last two years, the drug company Bristol-Myers Squibb has been funding pilot programs in diabetes care with three food banks across the country, each pursuing slightly different versions of partnership with local healthcare providers. (Here is some basic information on the project. More detailed data will be released soon.)BMS Diabetes Project 2014 The interim results of these studies provide us with some real data about food banks can play a vital role in screening, helping people control their condition, and also dealing with the huge swathe of ‘borderline diabetics.’ Here is a link to an informational website on this area, which has a lot of helpful info.

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We are actively speaking to a number of local health providers in our county about running similar programs. Virtually all of them have been enthusiastic about this. It is a big problem, they can save a lot of money, and they also have funds available for this type of activity. We are still working through how the financial model will work, but we are increasingly looking for fee payments (by healthcare provider, not individuals) for the type of direct service that we are providing in the healthcare space. We can’t be apologetic about asking these organizations to pony up. Yes, people expect charitable hunger relief for $25 bucks and a turkey too big for someone’s oven, but I can assure you that they do not expect to get bona fide health interventions so cheaply.

And now we will open up the stomach to determine that it is indeed empty.
And now we will open up the stomach to determine that it is indeed empty.

2. Consider providing training in screening for food insecurity for medical staff:

Oregon and its food bank are way ahead on this one. (what was that Ron Burgundy was saying in Anchorman II about only leaving the country once – when he went to Salem, Oregon?). They have a dedicated site with excellent online and written training materials for medical staff centered around utilizing the existing USDA two question survey to gauge food insecurity.

From childhood hunger.org
From childhoodhunger.org

Of course, medical staff will have a full-blown panic attack if you attempt to suggest adding anything more to the huge clipboard of paperwork needed to be filled in on patient intake (waivers to waive the right to waive waivers and the like). However, persuasive arguments can be made – continuing education points are available in the Oregon model, for which there are existing requirements for medical staff to obtain. Also, being aware that a patient is in a food insecure household is a pretty useful thing to know when you are looking at strategies to improve the health of that patient.

graphic-representation-of-fvrx
Prescription program

The other major potential sweetener is the possibility of providing doctors with the ability to ‘write prescriptions’ for fresh produce for some patients. They could then bring these prescriptions to a food pantry (ideally one that would be open at that time) where they could receive some fresh produce. Medical staff like to have something to give patients, and even if they have to pay something to help contribute to the cost of fresh produce, it is still a small cost compared to other interventions they could offer.

The health provider was particularly proud of their new mobile screening van
The health provider was particularly proud of their new mobile screening van

 

3. Get in on the ‘Community Health Needs Assessments’ wagon train:

This was supposed to be our admittance ticket, our way of building relationships with local hospitals and health authorities. They are now mandated to see what is happening with the health of their communities and devise strategies to deal with these issues. Food insecurity is a significant portion of this reality, as well as the health conditions that optimum nutrition can help alleviate.

We actually contributed to our local plan a few months back in terms of being invited to a stakeholder interview roundtable. We are still at the stage where we were not considered partners, more a case of ‘we better ask a bunch of nonprofits what they think.’ Consequently not much significant has resulted from our modest involvement in this process. In your area, you may be able to insert yourself at a more opportune point in the process and be more involved. From our viewpoint, I figure that we need to get on with the other things we are doing in this area, and then when next time rolls around, things will have shifted significantly.

Here is a download on this issue.Assessing and Addressing Community Health Needs_CHA_2013

 

fish

4. Stop whining that the bigger fish get all the fish food. Puff yourself up bigger to get bigger funding:

I am not talking about increasing the size of your organization, which may not be a good idea even if it is financially possible. What I mean is to link together with other food banks or similar organizations to run health based programs over a broader geographical area. While I may have my visionary moments,  most of the strategies I pursue have a very pragmatic basis. Such is the case with this. Trying to get the Feds to cough up for the dire needs of those in hunger in Santa Barbara County is an uphill struggle. Why, dear reader, even you are smirking now. What do they know about hunger? We always have to deal with the kneejerk reaction of having one rich city in a county with rampant food insecurity and low food stamp uptake. (In the 58 California counties, only 14 have more food insecurity than Santa Barbara). Also, the reality is that if you are looking for health money not USDA food security money, a county of 400,000 is a gnat bite. They want big populaces to make significant impacts on regional numbers.

This is one of the reasons for the formation of the ‘Food Bank Health Alliance of the Central Coast.’ This is an aggregation (currently) of ourselves, Santa Cruz and Ventura Counties. Between us, we have a million and a half people. If we can get San Luis Obispo and Monterey County to join us we will have an unbroken line of sister organizations covering the whole coastal region that separates LA from San Francisco.

Foodbank Health Alliance of the Central Coast logo

Our organizations are linked by MOU committing us to jointly seek for health related federal funding (though we’ll take money from USDA, Department of Defense, Smokey the Bear…). Marriages of convenience without shared values and objectives are a recipe for disaster – as I’m sure you’re all aware from your previous collaborations – however, this more open relationship is based on a shared outlook. This boils down to:

  • GOOD NUTRITION – Is the bedrock of our activities, sourcing and distributing as much nutrient dense food as possible. We also have nutrition and wellness policies so we can walk the talk (and help our member agencies do so).
  • COMMUNITY EMPOWERMENT AND DEVELOPMENT – As well as making a success of ‘feeding the line’ of people who are food insecure, we are also very focused on ‘shortening the line’ of those who will need help in the future. The only way to achieve this is through empowering the community to take control of its own nutritional challenges – on an individual and neighborhood level and upwards. This involves making those who were previously ‘clients’ into partners for healthy lifestyles and environments.
  • EVALUATION OF IMPACT – A need to move beyond measurement of outputs to demonstrating the efficacy of our actions on the public health and development of communities. We will additionally work to demonstrate wellness and self-sufficiency.
  • A HISTORY OF COOPERATION AND MUTUAL TRUST – We have a long shared history as members or partner distribution members of Feeding America, the national organization of Food Banks as well as the California Association of Food Banks.

There will doubtless be lots of challenges, different organizations used to running their own unique programs in their own idiosyncratic way. However, unless we can make this type of collaboration of very similar organizations work, then none of us have any hope at succeeding in collaborating with the wider groupings that will be necessary to have a true impact on poverty in America.

An ‘alliance’ like this needs large amounts of cash to grease the wheels and make it work, so stay tuned for results on how we’re doing. Or better yet, why wait to see whether we fall flat on our faces and put together your own regional collaborations. If the Feds don’t give you the money, they’ll only spend it on something really dumb, so you might as well go for it!

 

Gladys had waited 50 years, calculating the perfect time to make her move...
Gladys had waited 50 years, calculating the perfect time to make her move, snaring her hapless target in her macrame web of sin…

5. Lead with Seniors:

Often, funding to feed seniors is treated in a similar way to finding the money to feed homeless people. Besides a few highly motivated donors, these are the programs that it is harder to get broad funding for, so they tend to get paid for out of general operating expenses. It’s a shame, but scruffy dudes with matted beards or finicky grey hairs clipping coupons do not always excite funders. Consequently, it’s so easy to lead with kids and get funding for those kids. (I call it ‘taking candy with a baby’) Individual donors or foundations feel the heartstrings twang and they also think kids might be a better long-term investment. I have always muttered that ‘Kids are just the Seniors of tomorrow,’ but that hasn’t made much difference. I have been waiting for some perspective to shift or something to click for me in this area and I think it just did.

At a recent meeting with a major healthcare provider, he said: “Kids are basically healthy unless you really mess them up, but seniors are a significant expense.” If you think about it, asking the health world to pay up now to ease the problems kids will generate thirty years from now is asking too much. If we can help them keep seniors healthy and independent as long as possible, we can save them some serious cash in the here and now, not after they’ve retired or moved on. That is something that they would be prepared to invest in – and the sums would be a drop in the ocean compared to the increased expenses they face.

In this case I am thinking about a more integrated and expansive range of senior nutrition programs that move beyond the straightforward grocery bags or congregate feeding. These programs would have a nutrition and health element and that mesh more organically with existing health screening.

We are still putting together the right mix of ideas and partners before making a significant investment, but it has to happen and soon. We are seeing an explosion of need amongst seniors and what might be termed ‘pre-seniors’ (those close enough to retirement age that they are finding it very hard to get employed as people don’t want to invest training cash in them). Really, once you are in mid to late 50’s it gets harder and harder (So that’s why those Food Bank ED’s stay so long in their jobs!) To give an example of the type of programs we are looking at in the senior arena:

• A program providing ingredients for seniors to cook a meal together a couple of times a month at a community or senior center. This would give people motivation to keep their cooking skills going and also allows social contact, additional nutritional education and health screening from other healthcare groups.

• In seeking to meet the needs of our large Latino community, we are looking at a program that caters to the large number of grandparents who look after kids while their parents work. This program would also allow for a weekly meal in a community center where both generations would work together to cook a meal. This way, nutritional health and food literacy skills can be the focus for these two age groups, who if they disagree about a lot of things, are united in their belief that mom and dad can’t cook to save their lives, or that they are convinced they don’t have the time to. Again, this situation offers great health screening opportunities for diabetes etc.

• Meal delivery to seniors. In our area (and maybe yours) senior meal delivery has become a hot potato (or a reheated lukewarm potato, more like) with responsibility for the service being passed around. Meals on Wheels may be a large presence in your area or one that is suffering from a volunteer force that is figuratively and literally dying off. The reality in many places is either some kind of vacuum or spotty service at best. We are interested in investigating partnerships in this area. At one extreme, you can be like Feedmore in Virginia and create one big entity of MOW, food bank and community kitchen. At the other is at least more collaboration and integration within the range of services in your area. I know that Greater Chicago Food Depository has been piloting a program where health visitors drop off an ergonomic box of six frozen meals with low-income seniors that they visit. These are to be picked up from various centralized locations, and the frozen element allows delivery before food safety becomes a major issue. For the health visitors it is obviously an inconvenience but also provides something tangible that they can give people and that helps them make their numbers and keep their clients happy. This is a complex strategy and I know that there have been significant challenges with it, though this is clearly a direction worth pursuing and seeking the type of local and state reimbursement funding which would make it more financially viable.

It is up to you how tightly you are able to integrate this type of programming with the health screening and health treatment needs of seniors, but the tighter you do so, the more you guarantee a stream of funding. Food is still the draw to get involved in a program whether you are seven or seventy.

Feeding America recently published a report on Senior Hunger, which may provide some help to you in pushing for funding and partnership in this increasingly vital area of our operation.

Link to executive summary of this report: Spotlight on Senior Health

Are the tactics I have suggested a distraction from your core mission of feeding people? I would argue that they enhance the mission in multiple ways. Take the suggestion around training medical staff to screen for food insecurity. Can you imagine how much your development staff will benefit from the type of new understanding that doctors and health teams will gain of both food insecurity and our work to eradicate it? People want to get involved when the discussion is good nutritional health, and now is the time to start leveraging our credibility and boots on the ground in this area.

Also think about attending the ‘Closing the Hunger Gap’ conference, which has become a key focal point for this and related issues. Closing the Hunger Gap Conference Report 2013 which held its inaugural conference last year in Tucson and will next be held out of the country in Oregon in September 2015.

Live Long and Prosper, and let us know how you’re doing!

Funny-ice-cube-live-long-and-prosper-lol-spock-Favim.com-212681

Sick of Crunching Gears? How can you restructure your organization around your evolved mission

People are doing new things in the food banking world. In our search to ‘shorten the line,’ we are getting involved in areas that we had not been involved with in the past – educational programs, anti-poverty or pro-community development work – not to mention all manner of strange new alliances and partnerships.

Feed Gear stick copy

We are discovering that our existing organizational structures are not necessarily the most efficient vehicles for getting us where we want to go. ‘Feed The Line’ and ‘Shorten The Line’ can be like two sticky gears in a truck and if you are constantly crunching between them, your engine (read staff) can become overstressed and your gearbox (read budget) may get worn out with all the upshifting and downshifting.

tiananmen-square-1989-tank-man-china-close-up-one-tank

A standard food bank operation can feel like like tank, rumbling along, and when the situation calls for us to get all nimble and ‘ninja,’ we can find it hard to change direction. We’re brute force powerful, but maybe not so suited for the asymmetrical challenges of tackling poverty or helping clients build social capital. How can we build the nimbleness of being able to deal with both micro and macro interventions within our humble and creaky org chart?

We all hate org charts because they have this way of deadening a living, breathing thing (If you have any doubt, check out the chart of the educational establishment below):

Inspired?
Don’t you feel like you could die in one of these little boxes and it would take them months, maybe years to find your body?

Then of course there is the org chart according to the Executive Director’s view of the world, which is much like Steve Jobs’ view:

I am the chosen sun and you will revolve around me.
Hark! I am the chosen sun and you lesser celestial bodies must revolve around me.

For us to figure out what is the best structure for our organization, we need to start by being clear where we stand in relation to the community around us. [Here you can download a good SSIR article on the ‘Networked nonprofit‘]

When I am explaining to Foodbank supporters about the evolution of our mission, I talk about how we can no longer avoid looking ‘upstream’ of where we are, to try and understand and deal with what is driving so many people to our doors – typically situational or generational poverty.

I then tell them we need to consider what is ‘downstream’ of where we are operating – this means what are the true outcomes of our interaction with clients? It may be that their long-term health has not been affected as beneficially as we hoped. These ideas are summarized in the graphics I developed below:

Upstream Downstream1

Upstream Downstream4

Upstream 3

Upstream 4

Upstream Downstream copy

So, how can we restructure to meet this enlarged understanding of how we are affected by, and in turn affect the world around us?

Let’s look at some ways in which food banks are organized around these elements of the mission.

THE CLASSIC FOOD BANK

Potiphar was proud of his three-tier pallet racks
Potiphar was proud of his three-tier pallet racks

The first model is the ‘Classic’ food bank. Unreconstructed, proudly focused on the core mission and seeing no need to evolve further. Not only is it structurally unsuited for any expanded mission, it doesn’t even want to consider the possibility of one.

Typically this food bank will be in a high need / low resource area, where the only mindset accepted is ‘running faster and faster to keep in the same place.’ (Yes, I know my food bank is in hoity-toity Santa Barbara, but we serve the whole County, and of the 58 California counties, only 14 have more food insecurity than ours, so I should be at least be allowed an opinion…end of self-justifying whine!)

SB Postcard

Another factor is that whatever food bank we are in operates the way it does for a million historical and community reasons – many of which may be hidden under the surface. ‘We’ve always done it this way’ can  be a common refrain. These food banks will probably carry on much as they are, shrinking a little in size as ‘recession sympathy’ dries up further. The lack of desire to face shifting realities may be failure of leadership at the board or ED level or it could be just a lack of strongly voiced desire for anything more from the community.

Lets look at two other structural models that are currently out there in food bank land.

THE REMODEL

'The Remodel'
‘The Remodel’

The Remodel is basically taking the old structure and trying to add on a few additions. It might be teaching some nutrition education classes or having some involvement in SNAP outreach.

There are many food banks are in this grouping. Whatever gets added might be as a result of ED interest, community stimulus or Feeding America encouragement. The problem here is that because the organization was not structured for this additional mission, then the new initiatives can be like vestigial limbs hanging off the org chart or they shoved in some department that feels like its original remit has become distorted.

This can lead to new initiatives being left to die by staff who feel they are already overworked, or that the program will be starved of resources once it has been there a while and is more noticeable for the problems it is causing the organization as opposed to the ‘new program paint smell’ that was so useful for fundraising in the early stages.

THE SHINING CITY ON THE HILL

How did they afford a facility like that? Must have been selling all the poppies from the community gardens...
How did they afford a facility like that? Must have been selling all those poppies from their community gardens...

Of course the polar opposite of the ‘classic’ approach to food banking is what we might call the ‘We do it all’ or even the ‘Shining City on the Hill’ food bank. They stand out from all around them. They can be like a giant snowball rolling through town, picking up all manner of diverse activities: community gardens, job training, process kitchen etc etc. These activities are typically run by food bank staff. As someone remarked at the recent Feeding America ED forum, you’ve heard of ADD, this is called EDD.

This mode of operation tends to develop in places where the food bank is very much the ‘only game in town’ in terms of dwarfing other nonprofits, or having a large geographical area and considerable financial resources relative to the local nonprofit eco-system.

The general challenge with this approach is that it is expensive, difficult to sustain and challenging to coordinate. Also if you’re throwing a ton of programmatic outreach at the wall hoping some of it sticks, how do you know what element is really moving the needle, and what is well meaning but ultimately ineffectual?

CATALYST FOR CHANGE MODEL

catalyst

I would like to suggest one additional approach –one that I believe our food bank is evolving into, which is more of a bottom-up ‘redesign’ and which could be called the ‘catalyst for change’ model.

The ‘Catalyst’ model means we create an uber goal – in our case ‘ending hunger in our service area AND transforming the health of the community through good nutrition.’ This goal allows us to partner with a full range of local health and service organizations and hunger relief becomes part of a positive goal that can be measured using public health indicators.

The Vision Thing
The Vision Thing

In reality, we still have our fingers in a bunch of pies, but the difference from the ‘we do it all model’ – and this is crucial – is that the food bank needs to remain value neutral over whether things are done either by them, by their existing agencies or whether achieving something requires new forms of partnership.

The overriding thing is that your organization commits to making sure that it happens one way or another, will evaluate the results and keep the process moving forward.

We expand what may already have been a long-term role as the encouragers of an ecosystem of community partners working to improve health and food security. The difference is that this time we want results and we want to be able to measure them. It could also mean that everyone’s programs might not be adjudged as wonderful as everyone else’s.

FB’s are perfectly positioned to be the catalysts to make sure that the things that are going to help solve food security and promote health are being done in coherent and interconnected fashion.

• We’re not going anywhere soon, so we have stability.

• We have respect to broker partnerships and coalitions.

• We also have detailed knowledge of the range of programs in our service area and through our existing agency reporting we have some crude idea of the outputs of service.

• More than anything, we have the food. That has always been our ace card, but we’ve never really played it as hard as we could. We really need to leverage every pound of food we distribute to effect lasting change.

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This is all based around evolving the role of food within the organization. It is still central (relax…), but now it is not the end in itself. We are not only the food sourcers, storers and distributors – we are the food investors. We are going to leverage every nutritionally dense pound of food to bring significant long-term impact to the good health of our service area.

The price of doing business in the leverage is to provide good service to those who will always need food assistance as a result of challenges of age or faculty – yet even these folks can benefit from involvement in holistic service. Nevertheless, I am putting them lovingly to one side and saying that we will always find a way to source the food needed for these folks.

That leaves people whose lives we can impact significantly – children, families, those with chronic health conditions, those who question their limited voice or power in the community, those who want to share the skills required for good nutritional health with others in their neighborhood.

Being a catalyst sounds easier than doing everything yourself, but really it is just a different kind of difficult.

The below graphic shows the resources that we are providing in our area to stimulate effective nonprofit agency responses to local nutritional health issues:

This is what we are increasingly doing. How can we find an org structure that allows this to flourish?
This is what we are providing to agencies and clients in Santa Barbara. How can we find an org structure that allows these varied opportunities to flourish together?

If we have a traditional org structure then provision of the above services is going to look like the many-headed hydra. It also means that it is only a matter of time before one head or other gets lopped off, because it is not sustainable.

Let’s look at an alternate structure. Enter, if you will, through the doors of perception…

Photo of Don Draper in the final season of Mad Men. His transformation complete...
Photo of Don Draper in the final season of Mad Men. His transformation complete…

The doorway is a good metaphor, because people, food and resources can pass through it in both directions. So imagine your Foodbank in the center of the community (because it’s hard to escape from our self-obsessions) and further imagine four doors around you that lead in from and out to that wider community.

rebuild22

I am suggesting that this kind of restructure requires you to shift how you do business to facilitate the most efficient methods of stimulating two-way traffic through these doors. It means you have to inspire and join with and prod and poke your partners in the community (starting / but not ending with your member agencies) into embracing impact and sustainability and rigorous evaluation of their activities. And if you the food bank are going to initiate something new, you need to find a way to make it sustainable long term which means planning from the start of the process how the community will have assumed ownership of the project by the time it reaches maturity.

The four doors are:

1. Partner Organizations

2. Food Bank Programs

3. Development

4. Community Leadership/Volunteers

Let’s look individually at each of these ‘portals’ for food, energy, time and collective will:

Partner Organization Doorway

This is always going to be the biggest door. If we’re going to maximize our impact we need vibrant relationships with other nonprofit organizations. Yet we need to shake things up a lot in terms of how our current partnerships work.

We are already monitoring member agencies, but because our focus has  been about ‘maxing’ poundage, we have not pushed/encouraged agencies to embrace a ‘shorten the line’ agenda. Agency segmentation has been helpful for us in seeing who can be the best partners for ‘shorten the line’ services, but at some point, tough decisions need to be made about what relationships need to be prioritized for the good of the community.

We are in a time when traditional donated food supplies are tight and we are all working hard to find the next ‘wave’ of available product. Consequently this is the perfect time to make every pound count and  leverage existing relationships by expecting more of our partners that turning our inventory for us.

If the relationship with community partners is to become more about impact and not just poundage, then you might find yourself with a different set of partners. Some of our most successful new partnerships are not based around agencies distributing food for us. We are working with American Heart Association, who are providing some educational components to our existing educational structure with our Kid’s Farmers Market Program.

aha logo

We also are working with a local ‘cradle to career’ school initiative called Thrive, where our educational programs are helping them meet funding-mandated nutrition education requirements. We are in discussion with other potential partners around working together in community building and in food systems reform.

THRIVE_Carpinteria_Logo_-_UnofficialOur educational programs typically include a distribution element, yet in at least half of them, this is really a micro distribution compared to the ‘here’s 20lbs of broccoli, good luck with your life’ approach of the past. You might feel that this is mission drift, but I know that each one of these partnerships will have more long-term impact on increasing food security then setting up another mobile pantry.

Your existing agency relations structure may not be able to work with this expanded set of partners. For us there is already a challenge in how to work with two different types of partner within our existing agency structure. We need to do more to reconcile these types of partnership, so that the ‘non-food distributing’ partner does not become the poor relation (or vice versa). Close links between agency/partner relations and the work of the development and program departments now becomes crucial. The old siloed approach to information of the past can be disastrous in this kind of relationship.

FOODBANK PROGRAM DOORWAY

We are increasingly looking at pushing out our award-winning ‘Feed the Future’ children’s programs through our member agencies as a way of bringing them to scale and thereby meet our vision objectives. The programs are run by ‘super-volunteers’ and therefore are sustainable. Tapping into other agency’s ‘super-volunteers’ will enable this sustainable scale to increase. This represents another big element of the catalyst relationship – we can develop and evaluate programs and then our agencies and partners become the natural conduit for scaling these programs.

Feed the Future Program Cycle
Feed the Future Program Cycle

We need to make these programs (which all include both ‘feed the line’ and ‘shorten the line’ elements) so attractive in terms of curriculum, training and food availability and so effective that agencies will want to run the programs. Do agencies pay a license fee? Do we give them away? Do we ask them to provide some shared maintenance for the food element? For us, these issues are still to be decided.

We’re not big brother, but if they want to run a different program that is fine, as long as the evaluation and data connected to their program are broadly comparable so we know they are getting the impact.

"The war on hunger is within sight of victory."
“The war on hunger is within sight of achievable victory.”

A food bank running programs and fundraising to deliver them is not really sustainable in the long-term. Yes, you can always find a donor to pay for one nutrition ed program or another, but unless you have found a way to let the community take ownership of the program long-term, it will eventually languish. Which leads us to who should be running the programs.

COMMUNITY LEADERSHIP / VOLUNTEER DOORWAY

I believe the closeness of the relationship of volunteers to non-profit organizations is cyclical. At one end of the cycle, the focus is on an all-paid workforce with an overlay of marginalized volunteers to manual tasks or food sorting or packing. This can lead to disconnection from a large part community – especially professional people who have a lot of other skills to offer. One way of telling whether your use of volunteers is truly able to help you build impact is to imagine if all your volunteers fell away – could you continue fairly easily with your mission? If so then volunteers are really window-dressing for you.

At the other end of the continuum is more of a volunteer-driven organization. Aiming to become this is a major element of the ‘catalyst’ approach for us. We have a special category of volunteer, called a ‘community leader’ who is a super-volunteer that is treated pretty much as a paid employee would be. They are typically there to focus on a particular project, but others may have long-term loyalty to a specific program.

These community leaders are paid – just not with money. This ‘payment’ might be with the provision of written references, or with respect, or with being given leadership responsibilities. These Community Leaders are held to account for what they have committed to do and reassigned or fired if they do not produce. This has helped us scale our programs significantly.

I can’t pretend this has not lead to cultural strains within the organization, which naturally wants to shift back to just having paid staff. Employees find it easier to lead people who are getting paid to listen to them, rather than having to go to the effort of inspiring volunteers  will listen if we communicate effectively the power of our mission and the direct impact that volunteer can have on moving it forward.

We are making significant progress, though. I think there is something empowering for our employees in letting them know that they are all expected to be leaders of multiple volunteers, no matter what their job function is. It is all about multiplying their ability to achieve impact. Yes, we all know it feels so much easier to do something yourself rather than explain to someone else, but that is not sustainable.

The changes that this means to a traditional food bank structure is that you need a lot more ‘relationship manager’ type staff – they might be handling relationships with community leaders, short-term knowledge philanthropists that are working on a specific project, or outside organizations that we are partnering with. These are all people who need more attention / coaching/ focus than just the usual volunteer management skills. You are managing outside talent and it takes tact, organization and a clear understanding of the shared goals. We don’t really have the experience or skills in this area (besides in the fundraising arena) so it is learning a new skill and introducing a new culture, but the expectation is that staff will be managing an increasing number of community resources and so multiplying their impact as an employee.

Flip Logo Small
We can give you a bin of pears, but we can’t give you a small bag for you and your family to try.

As regards impact on the warehouse staff, if you have a rash of small scale educational programs that might require small poundage of high-quality produce or purchased items that are needed to demo a curriculum-specified recipe, these can be extremely difficult for current warehouse structures to deal with. Online ordering by programs staff becomes vital. Skills at staging and coordinating multiple micro distributions have to be developed. Drivers are overwhelmed by the number and complexity of deliveries and pick ups of programmatic materials from sites. In this situation it becomes increasingly important for volunteer drivers with loyalty to specific programs or sites to become involved.

Nutrition Advocates Logo

The other side of the community leadership equation for us is the way we can erase the dividing line between ‘benefactors and beneficiaries.’ Our Nutrition Advocates come out of our programs and  are encouraged to work more closely with both the Foodbank and become self-supporting groups. They are trained in food literacy, can be SNAP advocates and we also provide community organizing facilitation to help organize around any local health and community issues.

Community Leaders and Nutrition Advocates represent two powerful and brand new volunteer forces that are having a major impact in how our organization develops.

THE DEVELOPMENT DOOR

These other doorways suddenly open up a lot of other opportunities for the development department. We have community leaders teaching in programs and having direct access to working with clients so we are building the kind of long-term support from motivated professional people that no number of trips to the warehouse can generate.

The mantra in food banking has always been ‘once they go to the warehouse, they get it.’  This is true in terms of comprehending the size of our operations and the fact that we are not a glorified food pantry. However, if you really want to build long-term loyalty, you need to not show them the ‘tool,’  but involve them in what the tool has built. That means involvement in direct service with clients. The old hunger dynamic made this an awkward situation for all concerned. Now that our focus is about health, this is a way that benefactor and beneficiary can communicate as equals – we all care about being healthy, we all have ideas about how good nutrition can help with this. Teaching once a month in one of our programs is a golden way of building a whole new levels of ‘getting it.’

I used to get jealous about ‘Habitat for Humanity’ and their ability to involve supporters directly in their efforts by helping build a house and leaving them with the tangible results of what they have wrought. Community involvement with our programs now brings us ever closer to this model.

The desire to take more leadership in the health arena with local partners is also creating brand new funding opportunities with foundations, businesses and individual major givers who are looking for long term social solutions not short term charitable fixes.

One size does not fit all, and I am not suggesting that your organization should focus on the catalyst approach, like we are. Nevertheless, I  would challenge you to look at your mission and how it has changed and then start asking the tough questions around organizational structure, so that you can be ready to meet the challenges of the next twenty years as we work to achieve the long-term health and food security of our communities.

 

NOTE TO ‘FROM HUNGER TO HEALTH’ READERS:

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voting link – http://apps.facebook.com/walmartlocal/?applet=hunger&organization=184

In Search of the Holy Grail: Health Related Evaluation for Food Banks and other Social Service Organizations

holygrailIf you want to be a big celery-waving food bank then it is all about increasing your poundage, or should I say increasing what is the new guise of poundage – numbers of meals. (Even though by current reckoning, meals can be comprised of things like pounds of candy).

Nevertheless, assuming that you are doing your best to distribute pounds of nutrient dense food, surely providing more and more food to the community has to be a good thing right? Absolutely.

But is it also an effective measure of the success of food banks at ending hunger?

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Not necessarily, because this apparent success is also a strong indicator of the continuation (some might say institutionalization) of food insecurity in America. If we’re giving out more and more food, we are not shortening the line of people who need our services and so failing to bring lasting food security.

If times are tight for people and free food is available, then any smart person is going to take as much free food as they can get their hands on, providing that the distribution timing or environment aren’t so difficult as to make it not worth their while. People will then divert the funds they had for food to pay for some other expense for which there is not so much freely available help. It is the smart thing to do, and to be food insecure in America, you have to learn to be smart pretty quickly.

You can end hunger

We like to give food to anyone who says they need it without much in the way of preconditions. And who doesn’t need food? Your stated mission might be to ‘ameliorate hunger’ or ‘end hunger’ or if you are windy Californians like us then you might want to ‘end hunger and transform the health of Santa Barbara County through good nutrition’. Whatever your goal, we need a way of finding out whether we are succeeding at doing more than keeping the nutritional health of millions of Americans tethered to our life support machine.

Which is where evaluation rears its head.

Food banks are still better at demonstrating outputs (pounds, meals, people served) rather than outcomes (individual behavior changes, community change and societal change). Time was we could get on our high horses and proclaim that ‘ensuring a child didn’t go to bed hungry’ was an outcome as far as we were concerned and the most import one – oh, and by the way, how dare you even ask us to justify what we are doing.

A turkey at Christmas might have cut it for Scrooge, but we need a little bit more
A turkey at Christmas might have cut it for Scrooge, but we need a little bit more

Those days are over.

Whether you buy into the whole ‘nutrition bank’ thing or not, you are will still be noticing a gradual shift in how food banks are being perceived by larger foundations. A few years of recession were good for automatic and generous funding. Even now, knocking on the foundation door generally assures us of having our request for operational funding awarded at x dollars, because ‘everyone loves the food bank.’ However, the social service organizations who are winning the award of x plus x dollars are the ones who can successfully evaluate what they are doing and demonstrate impacts in the community. And sorry, that’s typically not the food bank’s grant application.

Gotta like the hat
Gotta like the hat

As a Mr. Potter-like CEO, I don’t like to leave money on the table, and I believe that there is a huge pile of money sitting on the table for food banks that we are currently not able to pick up more than a few scraps of – health dollars.

The Holy Grail for a food bank like ours would be the ability to demonstrate and quantify the contribution of our programs to lowering levels of childhood obesity, diabetes, food-related cancers etc. If we could do this, we would be in a strong position to be better funded with private and federal health dollars.

HolyGrail034

I want those dollars to continue the little nutrition revolution in our service area and I want them for you too, dear reader.

Despite the importance of exercise, it is clear that when it comes to the most effective and cost-effective way of maintaining good health, ‘it’s the food, stupid.’ Food is what food banks have and it offers us the potential to make an incredible contribution to the wellness of this country.

It is my belief that in the food bank network, we are sitting on the most powerful, most cost-effective preventative healthcare machine the country has ever seen. We just need to be able to unleash its power.

we_can_do_it copy

The way to do that is not to collect a few dollars to feed the needy, but to collect serious bucks to keep the nation healthy. By a combination of nourishment, education and empowerment, we can move millions of people – not just out of hunger, but out of hunger and into health.

Now, to kick me off my high-horse and to get us those health dollars, it takes evidence. And that takes evaluation.

Serena Fuller
Serena Fuller

This is where Serena Fuller PhD, the Foodbank of Santa Barbara County’s Health Education and Evaluation Manager comes in. Serena is a Registered Dietician with a background in obesity research (yes, lab mice are her friends) and public health. She has been on staff for about a year and a half now. When she was brought on board, the understanding was that part of her work would be to find this Holy Grail for us and deliver it to the development department so they could ride out and return with the gold.

Good scientist that she is, she had no interest in fudging the figures or finding some woolly way of claiming direct medical benefits from our programs that we cannot really prove.

Damn.

Getting over this disappointment, we moved on to a phase of having her dirty her nice white lab coat with the realities of food bank programs and for her to be involved in the creation of new programs. We also began to consider different evaluation options.

Have we found the Holy Grail? Of course not – it’s all about the quest, dude – but we did find what we believe is an important next step for us, which can also be replicated at other food banks.

It comes down to working with public health evaluation measures as opposed to medical evaluation measures.

reaim_badge

RE-AIM

We are now in the initial stages of piloting an evaluation approach based on the RE-AIM framework championed by Russell Glasgow. RE-AIM is an acronym for Reach, Effectiveness, Adoption, Implementation, and Maintenance and is an evaluation framework for public health type activities.

So why don’t medical measures work for food banks? Let’s get a teenie bit technical for a minute and look at the classic medical measures. (Take your motion discomfort pill if necessary)

childhood-obesity

BMI

Agencies often brag about ‘collecting BMI’ hoping that this covers a multitude of other evaluation sins. BMI is really just an indicator of later health outcomes, not what we are doing over the short term. Currently there is some question about whether BMI really is measuring what it is supposed to measure – total fat mass. It remains in use as a measure because of some clear positives: 1) it’s relatively easy to collect 2) it’s non-invasive and 3) it seems to correlate reasonably well with fat mass. Essentially some scientists have called into question whether it is good at telling whether people are actually healthy or not.

cholesterol-screening

CHOLESTEROL LEVELS

While total cholesterol, LDL and HDL cholesterol are measures for risk of heart disease that doesn’t necessarily equal myocardial infarction i.e. heart attack.  Cholesterol levels have also been critiqued in the literature as not being a sensitive or specific enough measure and thus have a low(ish) predictor value. But, just as with BMI it has positives as regards ease and non-invasiveness and it seems to correlate reasonably well with risk of heart disease.

WHY FOODBANKS SHOULD NOT BE COLLECTING MEDICAL DATA

The measures discussed, especially BMI, don’t change much in the short term, which is when these labor intensive measures are typically collected (expect in instances of multi-million dollar, long term, multi-clinic studies). Based on her experience at the Foodbank, Serena formed the belief that food banks should not be in the business of measuring subject-level ‘medical’ data because of invasiveness, the cost associated with this type of data collection and because of the issues raised above with regard to commonly collected medical measures. All this meant (in her favorite phrase) that ‘the juice was not worth the squeeze.’

The take away from all of this is that food banks can find their own measures of health, that are reasonable to collect, measures that can change in shorter amounts of time and which – just as much as with ‘medical’ measures – correlate reasonably well with the true health outcomes that interest us – long-term decreases in rates of morbidity (disease) and mortality. Being hungry sucks, but being grossly unhealthy or dead really suck.

These measures that we are most interested in are ones that score diet quality and food security scores.

Medical studies typically focus on populations that need to be similar in order for the data to make sense. But food bank populations are incredibly diverse and it would be unethical to exclude clients from the study if they needed food and their diversity doesn’t bode well for showing statistically significant changes in anthropometric, clinical and biochemical measures.

There is certainly the place for a few well-funded food bank research studies at a national level* (Check suggestions for these out at end of the post).

You may remember a post last year on ‘From Hunger to Health’ where I interviewed Dr. Hilary Seligman of UCSF, who was involved in looking at food security and how it can make major improvements in people with diabetes. There is also the Bristol-Myers Squibb project with Feeding America. It was discussions with Hilary which began to move us down the pathway that led to the RE-AIM tool.

RE-AIM

reaim

Because we want to run programs with the goal of improving the health of our community, we needed to find an evaluation framework that could capture changes in health.

RE-AIM has been used nationally to assess a broad range of community health interventions from actions to prevent child abuse through evaluating the efficacy of specific exercise programs for the elderly. A list of documents and links demonstrating some of these is contained at the end of this post.Here is a link to a monograph on using RE-AIM for program evaluation RE-AIM_issue_brief.

RE-AIM is unusual in that it moves beyond the current approach taken by the medical community to assess community-based interventions. In medical terms, the gold-standard is the Randomized Clinical Trial. In this, there is a focus on something called internal validity, which brings with it a tendency to oversimplify issues and their outcomes in order to isolate the impact of the program. Food banks don’t operate in a bubble. In particular, the emphasis on eliminating the potential for confounding factors typically results in samples of very homogeneous, highly motivated, healthy individuals which equates to samples of non-representative people.

RE-AIM hypothesizes that the overall social-change impact of an intervention is a function of all five RE-AIM dimensions not simply the client-based outcomes. The implication is that to have a substantial impact at the population level, an intervention must do reasonably well on all or most RE-AIM dimensions and thus all 5 must be evaluated or measured.

success score

Our Foodbank RE-AIM evaluation allows summary indices which we have termed ‘Success Scores’ which determine the overall impact of individual programs as well as initiative areas. We realize that the process will be iterative as we develop more measures with high reliability (measures the same thing over time) and validity (actually measures what you think you are measuring) and which include more stakeholders.

Our Success Scores have a range of 50 points, so as to be reasonably sensitive to the different activities we are doing right or areas that need improvement. However, we may find over time that 50 points isn’t sensitive enough or is overly sensitive and we so we will change the Success Score. That is the beauty and strength of evaluation over research in a community setting conducting translational work in that it is more flexible and dynamic.

Here is a link to an excel file that shows how we set the RE-AIM measures for a number of our programs.Program Score Card

Looking to the future the E part of RE-AIM (the effect) and the M part (maintenance) allow an organization to measure the ‘medical’ outputs if resources and will permit.

We are focusing initially on diet quality and food security because just like BMI and cholesterol levels they are reasonably well correlated with our outcomes of interest – adverse health events, long-term morbidity (disease) and mortality (death).  Plus if we are improving the food security status of our clients, the idea is that the demand for food bank services, in the traditional sense, will diminish and we will shorten the line.

We utilize well -accepted measurement tools for assessing good diet and food security:

Diet Quality measurement tool: http://appliedresearch.cancer.gov/surveys/chis/fvscreener/chis_fvscreener.pdf

Food Security measurement tool: http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/survey-tools.aspx

To measure food security means that food banks will need to change their model to a model like our Healthy School Pantry  or similar approach with wrap-round services like Fresh Place. Here are programs where people can get involved, become food literate, get enrolled in benefits, build their social assets i.e. meeting new people at the pantry, grow their own food, learn how to stretch their food dollar. This means we can track people who will still attend but move out of food insecurity.

The benefits of RE-AIM are that it can be customized to each individual food bank, community and stakeholders, is broadly focused with good external validity, assesses system-wide changes as well as individual changes, includes a maintenance component of making the program sustainable, which is vital when you looking at population-based changes in health status and food security.

RE-AIM can be undertaken by food bank staff and volunteers and doesn’t require highly trained individuals to collect the data, depending on what measures for E and M you have decided on.

The negatives are that there is still lots of data to be warehoused and collected, and that it can be cumbersome to gather the community input. The summary indices are only as good as your inputted data, and some sophistication is required in developing your measurement tools.

One example of how RE-AIM can help you monitor and make changes to what you are doing. Say you are running a distribution and conducting health education at the site. This health education is led by a trained volunteer and you collect your survey data from participants and see that you have no effective outcomes, (i.e. no changes in healthy food behaviors, self-efficacy, knowledge etc). If you were not evaluating the implementation you might just scrap the program, but utilizing the RE-AIM tool would help you notice the difference between this site and another site that had a translator. So the impact is really Impact = implementation x effect. The great part of evaluating implementation is you can learn which sites are doing great, learn from those sites and then take what you learned to other lesser performing sites.

We see the next stage as working to improve the measurement tools as well as identifying the best indicators, i.e. the measures the have the best predictive value of health impact, and tapping into the right partners so we that we can strategically collect ‘medical measures’. We want to develop an evidence library that supports food security and diet quality as the best predictors of morbidity (disease) and mortality (death) in light of community constraints, food bank constraints, invasiveness for subjects and related issues.

We believe that food banks could use RE-AIM to collect meaningful data about their impact on the health and wellness of their communities. We are developing the measurement tools, score cards and success scores, plus causal pathways and definitions.

If we all adopt this method I think we can have a large influence on what funders will expect and of what all of our respective communities view as our work.  This is turn can show the true impact of our work.  If we come together to say that diet quality and food insecurity are the right measures, especially when assessed in the context of RE-AIM based framework we will go very far in proving our impact from that of an earlier measure like Pounds Per Person In Poverty.

We need your input your comments on your systems, your criticisms – and yes, your dollars for continued development of a system that can bring considerable evalutory (did I just come up with a Palin-style coinage there?) benefit for the whole network. You can contact Serena at sfuller@foodbanksbc.org with ideas and me at etalkin@foodbanksbc.org with support!

Serena has put together a brief information sheet containing some aspects and definitions for RE-AIM which can be downloaded here.13-02-21 Evaluation Framework Definitions[2]

The quest for the Holy Grail continues, but until then, stay tuned. This won’t be the last time we consider evaluation issues in these pages.

Hold on, Indiana Jones found the Holy Grail, and it didn't turn out too well for his German buddies...
Hold on, Indiana Jones found the Holy Grail, and it didn’t turn out too well for his German buddies…

Useful links;

http://www.childrenshealthwatch.org/upload/resource/AdvNutr_JC_2013.pdf  (food security and adverse effects)

http://www.ajhpcontents.org/doi/abs/10.4278/ajhp.071211129?journalCode=hepr (RE-AIm evaluation of a health promotion intervention at schools)

http://www.biomedcentral.com/content/pdf/1471-2458-12-403.pdf (RE-AIM evaluation of walking intervention for employees)

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1200303 (diet changes health outcomes)

http://www.ncbi.nlm.nih.gov/pubmed/23280227 (all-cause mortality association with BMI)

http://www.ihepsa.ir/files/h1.pdf#page=525 (book – Health Behavior and Health Education Theory, Research and Practice 4th ed Glanz, RImer, Viswanath editors)

* OPPORTUNITY FOR NATIONAL STUDIES – There is certainly the place for a few well-funded food bank research studies which would be at a national level* – looking at BMI, adiposity (via BIA or caliper), HTN, cholesterol levels, long term blood glucose regulation, e.g HBA1C (which is different than evaluation), plus diet quality and changes in food security.

Are Non-Profits afraid of Competition? How can we tackle the root causes of hunger in America? Tough Questions from a Community Grantmaker – A dialogue with Mari Ellen R. Loijens, CFRE.

Mari Ellen Loijens

Is there a life after food banking? Apparently so. Mari Ellen Loijens worked in development for Second Harvest Foodbank in Santa Clara and San Mateo County from 2000 to 2004, and is now the Chief Philanthropic Development and Information Officer for the Silicon Valley Foundation.

Of course it is every fundraising professional’s secret fantasy to then go on to work at a foundation and give it away rather than have beg for it. (Without appreciating the challenges that go with such a responsibility). So what’s the difference between your time in the food bank looking out, and outside the food bank looking in?

When I was at the food bank, the needs were constantly growing. There was no single year where we had to feed less people than the year before, and I had a strong sense of urgency about the growing need. Now that I’m outside, it seems like it’s endless and I’m more anxious for real solutions to the issue.  It’s sort of like being an emergency room doctor, and your concern is how to bandage all the wounds for those who need immediate assistance. Then when you walk outside the emergency room, you think, “How can we avoid the people going there in the first place?”

That’s a question a lot of food bankers are asking themselves. Like me, they’ve seen the capacity of food banks grow with their success at fund raising and their ability to bring more food in to their service area. This has created more ongoing demand, so it’s kind of a spiral.  How do you think that food banks could get out of this demand spiral and move towards a long-term solution?

We really need to look at some policy changes.  We are a very wealthy nation and the notion that we have so many people who turn to others for such a basic need is troubling.  Clearly there is something wrong with a system in which many children go to school hungry.

Food banks and other nonprofits are always very reluctant about stepping into these waters, because they worry about offending donors whose political slant may lead them to believe that we are just ‘enabling’ people.  How can we navigate these waters?

Want to dip your toe in…

I think that the problem is that we focus too narrowly on just food.  If you only think, “I need to feed people,” and you think, “That’s my only issue,” then we’re back to the doctor in the emergency room who would be saying: “I’m trying to get people to stop bleeding, and it’s so expensive to keep using up all these wound dressings. So the solution is that we need more money for more wound dressings.”  It’s a symptom he’s dealing with, not the cause. In the same way, hunger is the not cause, it is the symptom of a greater problem in our system. This comes down to something like minimum wage.  Do we have a living wage?  Are people able to earn enough where they live in order to take care of something as basic as food and shelter? We have got to move beyond pushing for increased SNAP (food stamp) benefits and into the bigger issues like: How do we make sure people, who are able, can earn enough money to feed themselves and their families?

So, are you saying that hunger is a symptom of the condition of poverty, or of something else?

I think poverty itself is also a symptom. I’m not a socialist or a communist. I don’t believe that everyone should make the same money, but I do believe that Americans, if asked, would say it’s wrong to have a system which forces people to constantly be in abject  poverty and unable to get out of it, even if they are working hard, perhaps at multiple jobs.  At some point, we are going to have to make decisions about how we pay for our beliefs and values. In the same way we are asked to make tough decisions now about taxes and how we want to pay for the things that we believe our country needs, such as roads or to provide the fire and police services that we want. In the same way, we have to ask ourselves the question: if we think it’s wrong for a child in a developing country to make a dollar a day sewing t-shirts, how are we going to provide an adequate minimum wage so that people in America who work a whole day can feed themselves and provide at the most basic level for their families?

And so how do you see the situation in America now?

I think we have an unspoken social contract in this country which prevents people from moving up out of poverty, and much of that is as a result of not have a living wage in most places.  We also do not have systems in place that update the minimum wage as the cost of living modifies in an area.  The systems that we do have reward the wealthy and do not help the poor.  This means we have to really look at our whole social contract as a country and our value system and say, “Have we set in place laws that support the values that we claim are American?”

Bumper sticker seen outside Santa Barbara’s swankest hotel.

This is the point in the conversation where people begin to squabble about the meaning of the ‘American Dream.’ I see an unspoken fear in many donors I talk to. I would preface my comments by pointing out that these donors are caring and generous people who sincerely want to ‘pay it back’ and provide some level of support for those in need within their communities. However, they may have a voice deep within them, that reminds them how hard they had to struggle and sacrifice to get where they are, so why should they make it easy for someone else? They often don’t see the incredible daily sacrifices and struggles of those in poverty who can find no success story on the back of their struggle.

Whatever the sentiment, Uncle Sam gets pressed into service to wag that finger.

This is why food banks have been so successful, because there is a lot of interest in ameliorating the symptoms but a deep fear of taking the plunge to actually deal with the causes. Either donors are concerned that they will be heavily taxed and lose what they worked for, or they fear that the fabric of American society will change and everyone will expect things to be provided for them without working for them. Consequently they see America losing its ‘can do’ spirit of entrepreneurship and resourcefulness. The type of change that is required to actually deal with a problem is too scary. The same thing is true for issues of immigration, health care and the rest of the sad litany. This means we have to stand around with our hands tied or else harken back to some previous time in our country’s history where these problems were better hidden.

I think a new consensus for action needs to arise that returns the much-loved but threadbare teddy bears of left and right political philosophy to the nursery shelf, and for us to admit that we have grown out of them. They’ll always have a fond place in our heart they were both great in key moments at getting us to the point we are now at as a nation, but now they are getting in the way as our nation enters maturity. These security blankets are getting under foot and gridlocking our ability to do what we do best as Americans – which is to fix something in a no-nonsense straight-forward way.

“I’ve been manhandled so much, I don’t remember whether I’m Republican or Democrat.”

I know from over a decade of working to assist either the homeless or the struggling, that the amount of people sitting on their gluteus maximus and freeloading their way from society (amongst poor people, anyway) is absolutely tiny, just as the amount of people defrauding SNAP benefits is a minuscule amount in relation to the total. Are we going to allow an obsession with preventing the enabling of a few who don’t want to help themselves hold us back from making huge achievements as a country for the vast majority of Americans who work so incredibly hard?

Sounds great, we should import that stuff to America! (Cheaply, of course)

Can you imagine what greatness we could achieve as a nation if we weren’t all so consumed with fear about being able to get affordable medical help, or that we will be living in abject poverty as senior citizens? Modern free market economies are driven by so much advertising and marketing, that are showing people all the things they need to have in their lives to be happy. These forces provide a huge encouragement for people to produce more and earn more. If we can provide a counter-balancing support safety net for all Americans, it won’t extinguish this desire for more – which is equally part of the American temperament. The two can complement each other perfectly well. It’s not exactly a shining city on a hill, but it’s a workable system where we can all move forward at our own pace and to our own ability.

Forgive me for that. As a food banker, if you see a pile of pallets, then your natural inclination is to climb on top of them and start spouting off…

That’s quite all right, Erik. Keep breathing. Seriously, though, I think food banks need to get get braver about legislation. You need to move past the daily problem of feeding people, and start to collaborate with others that can focus on solutions and really start to ask the difficult questions of, “What’s the issue?”  Yet for reasons that you mentioned, like when you referred to SNAP fraud, I think food banks are very afraid sometimes of moving in that area, because if you did a survey of people you feed and even one person said, “Well because I don’t feel like working.”  That’s a terrible, terrible fear of food banks. Suddenly, no one might want to fund their food bank, because there is one person whose is working the system. So essentially, we are ready to punish and live in fear of that one person.  Well, there is always going to be someone working the system.  There are people who go to emergency rooms, because they don’t feel like paying for a doctor. We absolutely can’t set up systems to deal with that one person. We look at the big issues in our country like educations reform and how healthcare reform and you hear about those things all the time. I would love to hear our country talk about poverty reform.  How we are going to help make a sweep of changes that would impact the base line of our country and help bring people who are essentially stuck because it’s impossible to move on or move out.

So, who do you think are the right people to lead this movement or does it need to come from a ground swell at a local level?  

I think both. That is how the civil rights movement happened.  You start with that real grass roots movement from people who are experiencing the issues and people who support those people.  Then at some point you get the attention of people in a power position with legislation to be able to move those issues forward.

You mentioned that food banks are timid on the public policy front.  What else do you think food banks could do to make this happen? 

Well, I really like the ideas espoused in your blog about how your food bank is working on regarding entering the preventative healthcare arena. I do think that when you start to see yourself as part of a wider system rather than just an individual issue, then you are able to address bigger issues that have bigger impact. Poverty is not the root cause.  People became poor for a reason. The fact that they are poor is not the issue.  The fact that they became poor and can’t get out of being poor is the issue.

This requires food banks to build broad coalitions with other social service agencies in their service areas, some who may be member agencies and some who may not.

That is a challenge, because there is often reluctance for everyone to sit down and have a substantive dialogue about how do we move things forward?  The subtext from non profit leaders can often be: “I don’t really want to be in a room with them.  I don’t want to compete with them.”

Hey, you’ve been in some of the same rooms as me!

That’s the truth about a lot of nonprofits is they’re just completely uncomfortable with the idea of competition, and if I had the answer to this issue, I’d probably be able to save the world.

Nothing wrong with a little friendly competition.

Well, we’re non profits. Competition is way too business-like and vulgar for us, right?

Yes, you’re very sensitive souls. But, it has to start with non profits admitting it is an issue. Then I think, speaking as a funder, that there is a clear role for funders in facilitating this issue. I think it’s all power dynamics. The one with the power has the obligation. Foundations really have the obligation to reach out to the nonprofits and say, “I really want to know and I really want to understand what’s going on.  Why is this collaboration and conversation not working for you? Where they don’t have to sit in front of their competitor and say what their fears are. We can ask who would you want to collaborate with and how, on what terms?”  I think having an honest dialogue is what moves things forward. This sort of thing needs to occur one on one or in small groups. Large gatherings can neutralize everyone’s desire to make anything happen.

I think what you say about the competition angle is very interesting, because it’s kind of taboo to talk about nonprofits competing. To be a good non profit citizen, you can only talk in the language of shared impact and collaboration. It might be very liberating for people to also have a conversation about competition and to say it is absolutely all right. I presume there is fear that we would be acknowledging duplication of service if we acknowledged competition. Certainly something for people to consider starting a discussion about in their service area.

How do you think food banks and other human services and nonprofit should be thinking about evolving their funding streams over the next few years?

I think if you are looking for systems change, at some point that goes against the grain for sustainability, right?  You want to be working towards your services not being needed anymore. The ideal is that you want to be able to talk about what system changes are you creating, so that you should have to provide fewer and fewer services every year?  That should be the big boast.  “Last year we fed 200,000 people, but this year, thanks to our hard work, we only have to feed 150,000.”

But every nonprofit organization in the world is afraid to do that, because then they assume that the funders will come back and say, “Oh, you need less money this year.”  And so the organization declines.

I think that there is a new generation of funders that have a very different way of thinking, and that what people really want to see are problems solved.  People are tired of the same problems staying around for generations and generations.  You’re right, though. Every nonprofit I know like to boast about how they did even more; served even more. It is a treadmill. But this new generation of funders comes from a very different way of thinking that would say: “No, no, no. The metric I care about is not how many people you serve, but that you made systemic changes so you will have to feed fewer people moving forward.“ It is a way for your organization to evolve to be truer to its mission.

Mari Ellen, thanks so much for your ideas and for your work supporting non profits.

What Every Emergency Food Provider Can Do To Boost Client Health: A Dialogue on Food Insecurity and the Management of Chronic Disease with Dr. Hilary Seligman

Dr. Hilary Seligman, MD, MAS

Dr. Hilary Seligman, MD, MAS, is an Assistant Professor of Medicine within UC San Francisco’s Center For Vulnerable Populations and a general internist at San Francisco General Hospital. She is also affiliated with the UCSF Center for Obesity Assessment, Study and Treatment. Dr. Seligman’s work focuses on food security and its effect on the development and management of chronic diseases such as obesity, hypertension, diabetes and heart failure.

There is a reasonable amount of awareness about the health burden that food insecurity places on early childhood development, but not so much with adults, and I find that a really interesting element of your research.

We have largely ignored the long-term health implications of food insecurity among adults.  And so what I’ve tried to do is firstly figure out if there are health implications for adults, and – yes – there do seem to be important health implications.  They’re a little harder to talk about because it’s a little more complicated than just saying iron deficiency anemia, but I think the message needs to get out there that food insecurity has nutritional implications that are important, not only for children, but for adults too.

We all get so amped up trying to save the next generation that we forget the current one – and that would be you and me, folks!

At the recent Feeding America summit, you made a presentation that used diabetes as an example of the intersection between food insecurity and the successful management of chronic disease. (Food Insecurity and Health Presentation Feeding America Network Summit 4.19.12

A key element, which I think has wider relevance as we help our clients with their nutrition, concerns the cycles of food adequacy and inadequacy. We might expect a compensatory strategy of skipping meals, (leading to hypoglycemia) during times of food shortage, but you demonstrated that even when these people had enough food, it led to systematic overconsumption – people wanting to feast now that it was not a time of famine – which had similarly negative effects on the control of their diabetes, leading to hyperglycemia.

Yes, and food insecure adults required about five more physician encounters per year than those that are food secure.

In so far as the Food Bank Network touches an extraordinary number of people, and particularly people who are very high risk for the varied diseases that food insecurity predisposes people to, namely obesity, diabetes, and other diet-related diseases, food banks really present an unbelievable opportunity to be part of the solution to the nutritional inadequacy and the typical food-insecure adult diet.

So what do you think food banks should be doing to help address this situation?

Food banks often reach a person at least once a month, in a context that allows them to talk about diet and provide nutritious food.  People are much more willing to talk about their diet when they go into an environment in anticipation of leaving with food. And then it’s the challenge of what kind of food does the food bank provide, and how much of that food will provide a high nutrient value.

As distributors of food, we can potentially get stuck in a place of having to provide clients with donated food which may provide them with an overgenerous supply of calories but  that doesn’t do much to build their nutritional health. The other tough place is unsustainable spending healthier food, which even with the buying power of a food bank can be hugely expensive.

Totally. There are huge distribution and logistics challenges. I think what we have to do is take the first step which is to look at it and acknowledge that obesity and diabetes are a huge problem in the clients that are served by food banks and that food banks have the potential to greatly assist with that management.

We are now in a new situation where the ‘emergency food’ situation is becoming the new norm for a large number of our clients. Do you think that requires a greater degree of responsibility for what kind of food we are distributing?

It does. Food banks are being asked to feed people year after year after year because SNAP is underfunded.  And that’s where we get the problem.  It is the chronicity of use I think that makes essential an increased nutritional value in the food bank offerings. The other thing that’s changed is that an individual calorie has become so cheap that it’s really easy to get too many of them. You can get a lot of calories from poor food and feel full, but you won’t get any nutritional value from it. This is especially true of the food insecure clientele accessing services from a food bank or member agency.

Since the dawn of time, mankind has worshipped the Twinkie. (And it’s still fresh).

I’ve heard the argument that non-nutritional calories (Twinkies and chips and pretzels) are so cheap that anybody can afford those in the United States, and the food bank should only be there to provide fruits and vegetables and other very healthy food items.  That is a more extreme view, right?  That’s not necessarily my absolute view, but there is a certain value in considering whether clients can afford more expensive calories, and therefore considering what type of food that food banks should be providing in the future.

Why did this glorious union never capture the imagination of the Great American Public?

Particularly as access to these cheaper calories become more difficult for food banks, as corporations continue to become more efficient with their inventory. If the food in a food bank resembles the proportions of the contents of the USDA’s My Plate, that would be an ideal situation: half fruits and vegetables, a quarter whole grains and a quarter protein – lean meats and protein substitutes.

Our food bank is pursuing a steady transition to a specifically preventative healthcare agenda. Our goal is to leverage short-term relief of hunger and food insecurity into longer-term shifts of client behaviors around food leading to better health. This means an integrated series of programs starting with expectant mothers and following children through right up to the high school level. This means outcome-based evaluation, which is very challenging, yet we feel it is essential to gain the credibility to exist in this new and potentially very powerful space. However, we’re nothing if not a joyful ‘Heinz 57 Varieties’ of a network. Do you think that there is a lot that any food bank can do to move forward a healthy food agenda without having the particular focus that we have. 

Yes, I think every food bank can make big strides, whatever their resources or approach. The link between dietary intake and obesity and diabetes is clear enough that just documenting an increased intake or increased access to fruits and vegetables is enough to create an important public health message to the client group.

By the same token, you don’t necessarily have to show that BMI goes down or that diabetes is better controlled, because that link is well established enough. Just showing that fruits and vegetables are desired, they’re taken, and they’re eaten at home rather than ‘they spoiled and I threw them away,’ that’s enough.

Surely education – in what we like to term food literacy – plays a key role here?

Yes, the evidence in the academic literature suggests that protein is the most significant problem, because clients are reluctant to shift to non-meat proteins. Particularly in low-income communities, it’s not considered a meal unless you have meat, and that’s not the most nutritious message.  Other protein sources like beans and lentils and tofu are cheaper than meat and offer great nutritional value, but that’s an education message that we need to be communicating as well, and it’s often a hard sell.

When in doubt, have a festival! Still time to book for this August, Lentil Lovers!

What doesn’t seem to be as much of an educational issue is fruits and vegetables.  People like access to fruits and vegetables and will take them it when they are available, and when they take it, they eat it.  So the bigger educational barrier to me seems to be in the protein choices. In terms of fruits and vegetables, the big place where education needs to be done, I think, is with produce that people aren’t so familiar with, whether for cultural or other reasons. Particularly because these less familiar fruits and vegetables often end up at food banks.

Tell me about it! Every day for us is ‘Three Hundred Things to do with a Persimmon.’ Martha Stewart has nothing on us!

Only Martha could make Food Insecurity aspirational…

So, I would like to ask you what is your definition of optimal food security? How can we define it in an individual seeking our services and how can we measure our interaction with that person to know whether they are able to attain it?

That’s a great question.  You know, this is, again, my personal opinion.  People will disagree with me.  But I think that the way you know someone’s food secure is they’re not coming back to the food bank. Even if you report on a food security survey that you’re not worried about running out of food because of money, 99% of people who answer that they’re food secure on a survey administered by a food bank are doing so because they have come to rely on that food bank as a chronic source of their food intake.  And so they don’t need those additional food resources because they have the food bank.

I have a dream, where little white birds and little black birds pick up little spoons and feed all the boys and girls.

So where would you like to see the Food Bank Network in 5 years, as relates to this area?

I would love there to be some relatively straight forward way that food banks can record their product as high nutrient value versus standard nutrient value, so that there is a simple way to track improvement.

Feeding America is looking for other markers of success that are more nutritionally than poundage focused, and of course different food banks are already using systems such as CHOP (Choose Healthy Options Program) to rank their food.

Yes, though I think oftentimes they’re difficult to operationalize.  So I would love to see that food banks can set individual quality goals around improved nutrition.  Many food banks already have the skills around refrigeration and quick distribution, so it is more about developing the infrastructure for all food banks so they can respond if say a farm were to call up and say I have 100 pallets of broccoli, will you take it?  Many food banks would say, no, we can’t take that much because we can’t refrigerate it or distribute it quickly enough.  This is a hurdle that deserves to remain a major focus.

Hilary, thanks for your significant research in this area and for your support of and belief in the work of food banks.

RESOURCE

Link – Journal of Nutrition, 2010 February –  Food Insecurity Is Associated with Chronic Disease among Low-Income NHANES Participants


A Dialogue with Feeding America Director of Nutrition, Michelle Berger Marshall

Michelle Berger Marshall, MS, RD, LDN has the challenge and opportunity of helping both the national office and the network of 202 member food banks move forward to embrace a healthier food agenda. She has been with the organization in a variety of roles for three years. Prior to that she had broad experience with organizations like WIC and as a nutritional instructor at Kendall College, Chicago. I spoke to Michelle last week.

This blog encourages food banks to evolve towards a preventative healthcare approach with the idea that they will be able to find a new position of strength from which to leverage food and education to bring lasting changes in community health. How does this sit with what you are doing?

I’m a dietician and my husband is a physician, so we often have discussions about this area. If I succeed at my job as a dietician, I would hope to make his job far less difficult. Most of the people he is seeing in public health clinics have conditions which at the very least are exacerbated by diet. Prevention is the only way we can get back on track with the health of this country, and food banks have a relatively untapped power to address some of these complex issues in a simple way.

On your ‘From Hunger to Health’ website, you have laid out a framework of change that is incredibly powerful. As we ourselves have tried to engage with ‘public health’ organizations, it has been interesting to see what a disconnect there is between those who consider themselves anti-hunger advocates and those who have more of a community health or healthcare focus. We have a lot of work to do to bridge these conversations.

How would you typify the split?

One issue is that the public health sector traditionally doesn’t know or talk about food insecurity. At the same time I don’t think that anti-hunger groups have considered they are promoting or providing health. We find it easy to talk about negative aspects, like children not being able to concentrate in school without proper nutrition, but we haven’t been able to holistically tell the story about how all elements of the health argument connect together. However, we have made strides in making sure that we are now at the table with public health. At the local level, more food banks are joining obesity coalitions and such, and we are doing the same at the national level.

My belief is that for these partnerships to work, both sides have to bring something the other group wants to the table so that it becomes more than another well-meaning but ineffective conversation around nutrition. Food banks have an incredibly valuable asset – their clientele. We also have the food that can draw people to programs and screenings. If our local public health department are running a diabetes screening, that is not going to provoke a stampede to attend. But food is always a draw. Our Healthy School Pantry program is getting huge interest from our public health, because we bring back the same population each month. That is the kind of data they want, and the kind they can share with us to help us with our evaluations – that is what they bring to the table.

Absolutely, and the Bristol Myers Squibb Diabetes Project has been the perfect tool for us to begin to build closer links. We’re 9 months into 3 years of the pilot. Over the next year we will get some great data which can inform future projects. It has sparked a lot of interest. (An explanation of this Project is contained at the bottom of this post) I agree with your analysis on these blog pages that foundations are driving a lot of the new emphasis about impact, and in many ways we haven’t been able to provide that kind of demonstration of ‘here is the intervention and here is the impact.’ We as a network have a ways to go, but we’re getting there. We’re trying to bring in public health nutritionists and get them engaged in our projects to help us evaluate them. We recently undertook a nutritional analysis of the Backpack Program, with the University of Minnesota School of Public Health. ( Abstract or Final Report) Feeding America’s 2014 Hunger study will also include a series of health related questions for the first time.

The latest in cause-marketing technology – the begging bowl??

We always wrestle with language in this field. ‘Hunger’ is easily understood and can raise certain kinds of dollars, but is not always as accurate as ‘food insecurity’ which as an emotive rallying cry hasn’t exactly taken America by storm. Nevertheless, food security and nutritional health are so closely tied together that we are stuck with it for the foreseeable future. What is your definition of optimal food security?

We use the USDA definition (access by all people at all times to enough nutritious food for an active, healthy life). But I try to remind people that the key element of that is ‘active and healthy’ and I think that when we bring ourselves back to our core mission and to Vicki Escarra’s (Feeding America CEO) remarks at the recent Summit in Detroit, one part of our mission is moving food, but the other is addressing long-term food insecurity, and this makes us all think differently, not only about the types of food we are providing, but our engagement and the range of our activities in making sure that people can afford and access and consume the food that we know (and they know) is health promoting.

You have been heavily involved with the Nutrition Task Force, which produced a draft report that was discussed at Regional Feeding America meetings last year, and then I have not heard a lot more since about it being integral to their upcoming new strategic plan.

No, that’s not the case. The discovery and research phases are now over, and we are at the point where we are deciding what things we want to do, from policy down to technology and food sourcing strategies, and with incentivizing certain sorts of foods. The structure and foundation is there. These issues were brought up in strategic planning sessions, especially in the ‘Evolution of the Network’, and the recommendations coming out of our group are piloting strategies to help the network move in this direction.

Let’s talk a little bit about the challenges of rolling out the task force recommendations and the nutrition agenda in general across a diverse network. It feels like there is a lot more direct pressure from the Feeding America National Office on an area like food safety, whereas it can feel like nutrition is still a ‘would be nice, but we’re not going to push it too hard’ type thing.

As to the network, the overall interest has gone way past those you might predict would be interested.

What, us hippy Californians? You can say it Michelle.

No, you said it, Erik. We find many food banks across the country, large and small who want to take a more holistic approach. In the 18 months we have worked on this, the conversations we have had with the network have really evolved due to increased public awareness countrywide. People know about the diet-related disease crisis, and things like HBO’s Weight of the Nation will only increase awareness.

From the National Office perspective we want to make sure that nutrition is not a stand alone initiative and that we have a cross-functional charge – with our food sourcing team, our policy team, our philanthropy team, communications and research all acting in concert. That way it becomes less likely to drop off the agenda. We also have strong leadership support, which is vital for success.

What other challenges are there?

Lack of information about the food in our system. We all face descriptions of foods that can vary wildly, dependent on how the information is entered by someone receiving in the warehouse. It is often inconsistent, and more detailed information will need to be an key evolution. The same is true with the way that we measure nutritious pounds. We are looking at ways to do this, within our existing system constraints (31 categories) and trying to limit these to be more consistent with the ‘My Plate’ system, so we can use this as a platform. Down the line we want to look at long-term solutions to incentivize the sourcing and distribution of foods that are more in line with the dietary guidelines.

Will this be based on CHOP? (The Choose Healthy Options Program – a system first developed by Pittsburgh, which we use our own version of, which ranks the food in our warehouse as red (for low nutritional value) through amber and green (high nutritional value). It helps encourage us to tracking our abilities to source more nutritious food and also helps provide a guide to our 290 member agencies and programs about selecting the best items for their clients. Lots of green and maybe one red item).

No, CHOP is more of a nutrient analysis approach, which makes sense if you are looking at similar types of the same food, but the advisory team wanted us to move in a direction that was aligning more with the external environment. We want to promote foods that are in line with the dietary guidelines, so whole grains, fruits and vegetables, lean proteins and low-fat dairy. We also want to think about the negative nutrients that we want to limit – sodium, sugar, saturated fats. So the difference with CHOP is that we want to focus on food groups first.

What other perceptions in the network challenge the adoption of a nutrition-based approach?

One concern is that if we focus too much on nutrition and nutritious food, we simply won’t be able to meet the need (i.e. quantity vs. quality). This mentality is deeply tied to how we currently measure our success – in pounds. At the same time, what’s exciting is that as many members move in the direction of moving more produce and supporting efforts to not just move food but provide education, benefit assistance and community food security efforts, we start to see a significant shift in how we all think about our collective impact and our definition of success. At this year’s network summit, “measuring something in addition to pounds” came up countless times—now it’s time for all of us to determine what those other measures can and should be.

And then of course there is the argument that we are just emergency food providers, which has been debunked by Feeding America’s own recent report. We are providing a significant contribution to clients diets, so our previous role as Calorie Banks could actually have been making clients less healthy and more hungry.

One of my colleagues challenged that ‘we’re only an emergency response’ theory by turning it around—perhaps because we have limited resources and very few chances to have an impact on our clients health and well-being, that this in fact justifies why maximizing those opportunities is so critical. In that sense the question becomes not ‘why us?’, but ‘who else but us?’

CSI: Junkfood – All new Next Season.

What about the issue of choice? When I first put forward some of my ideas when Santa Barbara was holding the Western Region Conference back in 2010, some ordinarily pussy cat food bankers became rabid dogs when they discovered that in Santa Barbara ditch the candy and soda that comes to us rather than distribute it. My argument was that this choice already exists. It is very easy to get candy, but much harder to get nutrient dense food.

The ‘food police’ argument, yes. Within our network we talk about choices a lot, choice pantries, client choice, the choice system etc. I always find quite perplexing that when we bring up nutrition the opponents of this shift immediately use “client choice” as a reason not to focus on healthy food. I just have never understood this. Given the data and research surrounding food deserts, food access and the inequities that exist in so many communities (many of which are served by our network) it seems to me that by focusing and securing more healthy foods within our network, we are in actuality increasing the choices available for our clients, not decreasing them.

To me, the highlight of the work of the Nutrition Task Force has been the focus on ‘foods to encourage.’ Taking a positive approach is a wonderful way to nullify the ‘food police’ and other areas of concern.

I’m glad you think that. The framework of “Foods to Encourage” outlines the food groups promoted in the 2010 Dietary Guidelines and serves as a general philosophy to help guide everything from food sourcing to communication and education. Furthermore and most importantly it allows us to continue to talk about food as food, while still allowing for food banks to adopt more detailed nutrient based evaluation systems to make decisions within food categories should they so choose.

Food is a powerful modifier in our life, it can bring us down a pathway to good health or one that leads to poor health.

Exactly. Every person on the planet has a relationship and personal experience with, (and subsequently an opinion about) food, it’s a struggle to have an objective dialogue about the issues. In some ways that is what makes these issues so challenging to tackle. Food has power, is often emotionally charged, deeply rooted in one’s culture and community, and provides much more than just energy and nutrients. When we attempt to make black and white decisions, it doesn’t take long before we realize when it comes to food and nutrition there will always be a lot of gray.

Foods with all the colors in the rainbow…and some that aren’t.
Forget about the food, they have way better hats.

Perhaps key to all of this is unlocking the power of the communities themselves, to fight for an environment that allows all people to make the choices that allow them to nourish their families and live healthy, productive lives. As the food bank network we need to see our work as part of the solution today and in the long-term, our core work of hunger-relief does not need to be mutually exclusive of health promotion or vice versa. Everyone brings something to the table and I tend to believe food banks know food better than any other group.

Where would you like Feeding America and the Network to be in 5 years from now?

I would like to see nutrition fully integrated into how we see ourselves as an organization. Currently, you might go to our website and we talk about food security and hunger and then you have to go to different page to find out about nutrition. The earlier disconnect that I talked about with public health is also there to some extent within our own organizations. To truly bring together the goals of better nutrition and building food secure communities requires full integration. It needs to become engrained in how we do business, talk about ourselves and envision our future.

Thanks Michelle for all your great work.

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BRISTOL MYERS-SQUIBB/FEEDING AMERICA DIABETES PROJECT

The Need: Individuals who have immediate food needs may be at risk for nutrition-related problems such as type 2 diabetes. For all diabetics, diet is a critical part of managing their disease type. For diabetics who are also facing food insecurity, maintaining a healthy diet can be nearly impossible, however. A research study conducted by the University of California at San Francisco found that adults living with the most severe levels of food insecurity had more than twice the risk of diabetes than adults who have ready access to healthy foods. By providing nutrient-dense food and nutrition and disease education, food banks can help their own clients with type 2 diabetes and those referred by health centers adhere to the diet and lifestyle changes that are prescribed, but are impractical due to lack of access and affordability.

The Project: Feeding America and 3 member food banks in Texas, Ohio and California will collaborate with health care providers to improve the health outcomes of individuals who are food insecure or at risk for food insecurity and also affected by type 2 diabetes. They will create and pilot bi-directional food bank-health center partnerships that will provide diabetes screening, care coordination, nutrition and disease education, and healthy foods. Feeding America will evaluate how well the project improves diagnosis of diabetes, adherence to diabetes treatment, increases self-care skills, maintains or increases mental wellness, lowers risk or presence of depressive symptoms, and improves specific physical outcomes related to type 2 diabetes such as Ha1c.

Foodbanks participating include:

Food Bank of Corpus Christi www.foodbankcc.com

Food Bank of Redwood Empire www.refb.org/html/innovative_programs.html

Mid Ohio Food Bank www.midohiofoodbank.org/pdfs/EHhd/BMS-MOF-Release-Together-on-Diabetes.pdf