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.

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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.

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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.

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