Building Food Security Street by Street

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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.

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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.

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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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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

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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.

Restarting the SNAP discussion in your community – by utilizing a ‘Food Security Challenge.’

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At last, a Foodbank CEO shuts up long enough to actually sling some groceries!

Talking about SNAP to many of our traditional supporters can be like talking to our teenage kids about sex. We know we really should do it and it will be good for them, but we’d rather put it off, because the conversation is probably going to go south. We’ve all stuck our fingers on the mousetrap many times and watched it SNAP on our sensitive little digits.

Hey, Mr/Ms Donor - let's talk about food stamps!!
Hey, Mr/Ms Donor – let’s talk about food stamps!!

Foodstamp challenges are nothing new. FRAC have been pushing them and have a toolkit on their website. But I thought I would share my personal perspective on how to execute one for maximum benefit to your organization.

FRAC Logo

Who can really turn their back on heavy involvement with SNAP outreach these days? People need food help, and it doesn’t matter whether the food passes through our warehouses first or not. As traditional sources of donated food have shrunk, making sure that people are taking full use of federal benefits has become more important than ever.

You can only get so far with promoting SNAP before someone on your board or a donor is going to get outraged about your food bank spending scarce resources promoting a federal benefit.

food-stamps

You cannot say the words ‘food stamps’ to someone without eliciting a visceral response. Sometimes it unlocks fears of ‘there but for one paycheck go I’ or other reactions that run the gamut from outrage about fraud to outrage about disempowering people by paying them to be ‘losers in a winner/loser society.’ Emotions run high, and so does lack of knowledge about what food stamps actually are and do.

How can you begin to get this knowledge over and get people to step out of the trenches of their assumptions and take a different view of the world for a while? I’m discovering that a ‘Food Security Challenge’ is a great way of doing it.

You may have read the recent press coverage of Newark Mayor Cory Booker’s ‘food stamp challenge.’ He committed to living on food stamps for a full week and regaled us with up close and personal accounts about burning his yams and becoming grumpy without his coffee. After getting through the week, he announced to the press that he was going to run for Governor.

Cory’s Yam R.I.P. – It did not deserve to be burned at the stake
Cory’s Yam R.I.P. – It did not deserve to be burned at the stake

As CEO of the Foodbank of Santa Barbara County, my job is to find those yams and get them out to the Corys of this world. Surely a single week of little money for food wasn’t too much to handle. How about a month? If I could live on food stamps for a month, it would give me more of the true flavor (or lack thereof) of the challenges that our clients face every day.

Could a picky eater like me with my rice vinegar and my jasmine tea make it through on $6 a day? (this is the rate in Santa Barbara County, based on higher cost of living). What kind of help from the Foodbank and our member agency programs could I get to supplement the SNAP? Cory ran for Governor after a week, maybe after a month I could run for Secretary-General of the UN…

I started my Food Security Challenge thirteen days ago, so I’m nearly half way there.

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The idea is that throughout each of the four weeks, I explore a different aspect of living on food stamps, from signing up for CalFresh (California’s name for the food stamp program) to finding out what nonprofit services are available to me as a resident on Santa Barbara’s Eastside; from learning how I can grow some of my own food, to seeking resources to help eat healthy with limited funds. During week three, the Challenge encompasses a national perspective, with a visit to food distribution centers in Chicago and a meeting with Feeding America about the national food stamp situation. I will spend part of the final week of the Challenge living in my car, turning to the services in the community that people and families who have recently become homeless might experience.

So, some readers are laughing by this point and wondering whwther there are actually any hungry people in Santa Barbara. Truth is, there are only 11 more counties in all 58 California counties which are more food insecure than Santa Barbara. So maybe there is trouble in paradise.

'In Every Dream Home A Heartache.'
‘In Every Dream Home A Heartache.’

So here is my advice about running your own challenge.

ELEMENTS OF THE CHALLENGE:

NAME IS KEY: FOOD SECURITY CHALLENGE

Not food stamp challenge, because the message we are trying to get over is that food stamps alone are not enough to provide food security. It also sets up a wider focus that will allow you to promote the totality of your agency’s and partner’s activities.

PLAN AN EVOLVING SCHEDULE OF ACTIVITIES AND EVENTS

To keep the message alive for a week, for a month, requires an evolving story with fresh twists and angles. The more this can be planned in advance the partners. Look at what programs are happening and how can they build in? Who would you like to interview or involve and use the challenge as the basis to do this.

GET A VARIETY OF PEOPLE ON THE CHALLENGE

Our version of the challenge is just me as the Foodbank CEO being involved. (My family declined to participate – because daddy/hubby can take his publicity stunt and shove it). This singular participation is fine locally, because I operate in a relatively small media market, and we work with a local PR company, so it is possible to get a lot of media exposure. But in a larger media market you would want to get as many different groups as possible taking part: board members, young people, foundation staff, media people. More people means a multiplier factor in terms of types of stories. Part of the fun of our local challenge was that I encouraged people to phone the Foodbank if they saw me cheating.

FIND THE RIGHT MEDIA PARTNERS

We made an agreement with a widely-read local free weekly magazine, the Santa Barbara Independent to be the main media partner. I produce an article once a week for each of the weeks which is featured in their online addition, with more detailed coverage in the print edition at the beginning and end of the challenge. We found that a lot of other news outlets were also interested in running stories too.

LOCAL IS BETTER

Booker was looking for national press (which given his next step was hardly surprising). I think our food security challenge has been such a success because our focus has been local. No one on the other side of the country gives a darn about some whiny food bank CEO in supposedly frou frou Santa Barbara is bringing his work home with him for a month. But locally this was challenge has ignited a lot of interest. The media want to deal with ‘the plight of the needy’ and they have their go-to stories in Christmas, but what about in the early time of the year, when no one gives two hoots about your regional food bank?

If you personally are taking the challenge it is great to take advantage of what services would actually have available to you. Unless you live in a gated community miles from nowhere, you will have some kind of distribution nearby. If you are in some suburban neighborhood, well that just highlights the ‘new’ face of SNAP participation.

I have been visiting all the local distributions I would be able to access. I don’t actually take the food, but note what I would have received and then go buy it somewhere else. (The same is true with the SNAP money. I operate with $200 to represent the total amount of money I would have received for a month of SNAP)

BLOG AS THE FOCUS FOR BUILDING COMMUNITY

I created a separate blog  to post regular updates on my exploits. Traffic is pushed toward the blog from other sources, from our own website and from my limited tweeting ability. One of the coolest added benefits of the blog is that it has created a forum for individual families to their share stories in the comments section. Responses to blog posts are a great way for people to go public about an issue they would be very reluctant to weigh in on in any less discreet type of media. I have been responding personally to the comments, which builds up trust and will perhaps encourage people to allow us to be more specific in using their stories in wider media.

SNAP DISCUSSION IS THE BEACH HEAD FOR A MORE DETAILED UNDERSTANDING OF THE WIDER RANGE OF YOUR PROGRAMMATIC AND ADVOCACY ACTIVITIES

Once you get blog readership, then you can begin to feature programs as I did by inviting a local supervisor to attend one of our Healthy School Pantries, which contains a Calfresh/SNAP outreach component.

Feed the Future Program Cycle
Feed the Future Program Cycle

INVOLVE THOSE ADMINISTRATING SNAP

As well as highlighting your own outreach efforts, Involve local DSS or whoever is the administrative body for SNAP in your region – I went to interview three staff members at different levels about their challenges, myths, how they deal with public perceptions and of course the challenge of politicians doing demonstrations outside their front door because they want to cut down on ‘rampant SNAP fraud’ because they can’t actually think of anything constructive to do, so this will be a nice easy piece of red meat to throw to the crowd. This helps strengthen future relations as well.

The DSS version of the iPad! But you can only push one button, so make it count.
The DSS version of the iPad! But you can only push one button, so make it count.

KEEP A STRONG FOOD FOCUS

I have featured recipes, detailed lists of what food I got from distributions or purchased with my SNAP money. I also let people in on my bargain hunting and comparison shopping. People are very interested in this kind of micro level food stuff. I am also keeping a food log of my meals which our dietician will be looking at. These activities also give the opportunity to bring in local chefs to help you make the most of what you have, and this provides another good media angle.

Microsoft Word - 13-01-15 HSP Baked Macaroni and Cheese with Mar

FEATURE A WIDER GEOGRAPHICAL PERSPECTIVE AT SOME POINT

It will be easy enough for you to find a state, National dimension and Feeding America – You know how it is, people are always interested in how things are so much worse/diiferent somewhere else. I will be interviewing Brady Koch the SNAP outreach czar at FA and attending a SNAP outreach and distribution sponsored by Greater Chicago Food Depository, which will take place on the South Side of Chicago.

Feeding America Logo

CONSIDER A PUBLIC FORUM

This is a great way to wind up the challenge. Local political representatives can be invited. After the media interest, you should be able to get a larger attendance than normal for this type of event.

KEEP HAMMERING HOME THE MAJOR EDUCATIONAL POINTS

Message 1

For us, the main goal is to get over the idea that SNAP plus local services equals an effective safety net. Lessen that equation in any way and the whole thing doesn’t work.

Message 2

Food Literacy and empowerment is not ‘nice’ it is essential. The type of practical nutrition and cooking training we do is vital for those who are facing a potentially bland diet with little funds to put toward good food. This is about skills that people can utilize your food effectively with, rather than pat recipes. These skills are especially important to be able to make good use of fresh produce.

CONCLUSION

The Food Security Challenge is not a gimmick; yes it’s proving great to promote the Foodbank’s work in this little understood area, but it’s also chance for me personally to keep in direct touch with how the Foodbank is trying to move people from hunger to health.

Toxic Charity : How Service Providers Can Hurt Those They Help (And How to Reverse It)

Previously in these pages we have questioned whether some of what we do to help clients through our distributions and programs might actually be having a negative effect on the long term health and independence of those clients. Earlier this year I interviewed Jan Poppendieck about her book Sweet Charity, which addressed some of these concerns.

Today on ‘From Hunger to Health’ provide a review of another book, Toxic Charity by Robert Lupton, ED of Focused Community Strategies (FCS) a respected community development organization operating in inner-city Atlanta.

Bob Lupton

The book was published last year, and this piece also draws elements from an interview with the author that took place this week.

What does it say to you?

Let’s start out with a little Rorschach test on your attitudes to our work. How does the following quote land with you?

Give once and you elicit appreciation;

Give twice and you create anticipation;

Give three times and you create expectation;

Give four times and it becomes entitlement;

Give five times and you establish dependency.

Does it piss you off? Do you default to a stance that everyone deserves enough food therefore dependency doesn’t even come into it? Or maybe you kind of agree with it. Whatever your response, I would bet that you will find a lot to chew on in Robert Lupton’s book.

“Food in our society is a chronic poverty need, not a life-threatening one. And when we respond to a chronic need as though it were a crisis, we can predict toxic results: dependency, deception, disempowerment.”

His basic supposition is that a lot of what NPOs and churches do to assist people has a negative rather than a positive result. He is not questioning people’s motivations, but rather the unintended consequences of rightly motivated efforts. He believes that if ‘emergency’ relief does not transition to development in a timely way, then compassion becomes toxic.

Excuse for gratuitous picture of the Toxic Avenger, for those of us of a certain age, with a certain fondness for Grade Z movies.

He provides an ‘Oath for Compassionate Service,’ which is meant to be a guide to the provision of services:

The Anatomy of Giving

Lupton describes his own experience of handing out boxes of groceries from one of his church’s food pantries. He began studying the facial expressions and the how recipients seldom gave him eye contact. The body language of the recipients was head and shoulders bent slightly forward, self-effacing smiles and meek ‘thank yous.’ He observed how quickly the  response to charity devolved from gratitude to expectation to entitlement. He then observed his own part in the ‘anatomy of giving.’

Step right up...

“I expected gratitude in exchange for my free gifts. I actually enjoyed occupying the superior position of giver (though I covered it carefully with a façade of humility). I noted a hidden irritation at those who voiced their annoyance when free food stocks ran low. I grew weary of filtering through half-truths and manipulative ploys as I sought to equitably dispense resources.”

After 6 years of running homeless shelter kitchens I would have to agree with Bob’s observation of the attitude he observes in himself and others. He says that doing for rather than doing with those in need is the norm. Add to it the combination of pity that can become patronizing with unintended superiority and charity becomes toxic.

Big is Bad, Small is Good

Lupton spends a good chunk of his book looking at the sometimes misconceived results of church foreign aid trips, and disempowering nature of aid to Africa, but he also provides a detailed demolition job on the work of TAP (The Atlanta Project) born out of Jimmy Carter’s desire to eliminate poverty in Atlanta prior to the 1996 Olympic Games.

JC (the other one) and MJ at a TAP Event in 1993. It almost makes your nostalgic…

This top down approach to community development spent countless millions to leave behind a situation that was actually worse at the end of it. He also looks at the Faustian bargain that was the Salvation Army’s acceptance of a mega donation from the Kroc Foundation to build huge Kroc Centers that would centralize a vast array of social services. While this is convenient for the economies of scale of the service providers, it has the effect of drawing people from miles around to access the services and so distorting the normal societal fabric of the area around.

Asset Based Community Development – The Ninja Star version

Lupton favors the Asset Based Community Development (ABCD) model (More on this in a later post) and his own organization in Atlanta operates on the smallest neighborhood by neighborhood approach. He also musters a pervasive though depressing argument about the effectiveness of microloans overseas and the reasons why they would not work in this country, except for with first generation immigrants. (He has nice things to say about ex-Feeding America CEO Vicki Escarra’s new organization, Opportunity International).

Working for Parity of Relationships is key

Lupton talks about ‘Parity vs Charity.’ That it is a very delicate undertaking to develop authentic parity between people of unequal power. But relationships built on reciprocal exchange (what he calls holistic compassion).

When Justice and Mercy Meet

Lupton identifies compassion as a powerful force, a stamp fo the divine nature within our spirits. It lies within us all – from tender child to hardened criminal – waiting for the right trigger to set it off. Mercy is a power that compels us to acts of compassion. He indicates that the Bible places equal emphasis on both mercy and justice. “He has shown you, O mortal, what is good. And what does the Lord require of you? To act justly and to love mercy and to walk humbly with your God.” (6:8, NIV)

He breaks this down:

Act justly. Justice is fairness or reasonableness, especially in the way people are treated or decisions are made.

– Love mercy. Mercy is compassion, kindness or forgiveness shown especially to someone over whom a person has power.

“Twinned together these commands lead us to ‘holistic involvement’. Divorced, they become deformed. Mercy without justice degenerates into dependency and entitlement, preserving the power of the giver over the recipient. Justice without mercy is cold and impersonal, more concerned about rights than relationships. The addict needs both food and treatment. The young woman needs both a safe place to sleep and a way out of her entrapping lifestyle. Street kids need both friendship and jobs. Lupton identifies that mercy combined with justice creates:

– immediate care with a future plan

– emergency relief and responsible development

– short term intervention and long-term involvement

– heart responses and engaged minds

“Mercy is a door, an opening, an invitation to touch a life, to make a difference. But it is not a destination.”

I believe that this resounds heavily within our work in ‘emergency’ food provision. We know that the vast majority of what we are now dealing with is the chronic situation not the emergency one. It is time we owned up to the responsibilities and possibilities of what we are involved in.

What is the real ROI that we are seeking with our billions of pounds of food? Those who read this blog will know that I believe that this return is in terms of a huge impact on the preventative healthcare of our communities and by using food banks to leverage and co-lead community development efforts.

What is the way from here to there? How do we transition from emergency relief to development? We could do worse than follow the steps suggested by Roger Sandberg, Haiti Director of the NGO Medair. He describes a progression of three steps:

1. Relief – Responding to the initial need. (We’ve already achieved this).

2. Rehabilitation – This overlaps with the first stage. It is anything that increases the capacity of a local community enabling them to respond to future crises. (This would include nutrition education and empowerment programs that a food bank can run or champion, and I am sure you can suggest lots of other things at this point in the continuum.

Lupton promotes food bank-supported food cooperatives as a replacement for food pantries that ‘offer free food at the price of recipient’s dignity.’ The cooperatives he mentions in his book are run by Chad Hale of the Georgia Avenue Minestries.

This organization is a member of the Atlanta Community Food Bank. Co-op members pay $3 biweekly dues for $30 worth of groceries. (More on the pros and cons this approach in a later post – if anyone wants to share any experiences, that would be great).

3. Development – This overlaps the other stages too. Development work is long term. It seeks to raise the standard of living and the quality of life for a population over many years. (This corresponds to the work a food bank can do creating jobs, assisting with community organizing and partnering with coalitions to work on long-term change in service areas).

Lupton believes that currently, the food bank network as a whole still remains on the sidelines of these efforts. Many food banks have great untapped potential to be involved in community development, but are shying away from it for a number of reasons.

 “Erik, I’m glad that this discussion is coming up. It is encouraging that an increasing number of food banks are reconsidering a more community developmental approach.”

It is not unfair to Lupton to say that he doesn’t necessarily have a lot of answers about what the role of food banks should be in fostering this community development approach. He is clearer on the negative effects of some of what we do now.

That means it is up to us to create this vision for ourselves, in collaboration with our communities and our member agencies.

There is a lot of potential for new ideas and scaling of existing ideas. These are exciting times to be a food banker.

AFTERWORD: I normally stir up the odd vociferous reaction to my posts, and these sometimes upset those on the political left and the right equally. This is usually an indication that I am on to something interesting in my waggling of tooth nerves. The latest post is no exception. People are way too polite it seems to leave stinging comments on the actual blog, but send me emails instead, which is a shame. I am happy for a little public pushback.

The reactions to the Toxic Charity entry largely indicate a concern that this is some kind of right-wing agenda to ‘blame the poor’ for their situation and to cut them off from help. I don’t see it this way at all. I see it more of a case of ditching kind but ineffectual  low-touch help and replacing it with long term relationship and commitment to make change in the community (which is the best help of all).

I think it is one of those situations where when we touch a sensitive area, then everyone retreats to a defensive position, sensing criticism and judgment and thinking they hear the things they are expecting and dreading to hear. I’m the most sensitive, touchiest little soul there is, so I am just assuming that others are the same.

It may be very uncomfortable for people to deal with Lupton’s criticisms of things that are close to our hearts, but I think if you look into what he is recommending in its place: Asset Based Community Development, you will see that this is not some kind of harsh ‘fend for yourself’ approach, but involves us helping each other in a deeper, more lasting way.

As I get into this work, I find the default approaches of left and right to be increasingly unhelpful and out of touch with my experience of the world. 

Food Pantries with Case Management build both Measurable Food Security and Self-Sufficiency

Some of the themes that have been bubbling up in recent posts have concerned food banks searching for ways to impact client’s lives for the longer term, and then how we might be able to measure that improved food security and self-sufficiency.

This week I am looking into the success of the Freshplace pantry in Connecticut, a collaboration between three community organizations: Foodshare, the regional food bank, the Chrysalis Center, which is a social service agency, and the Junior League of Harford, a volunteer organization.  The difference between Freshplace and traditional food pantries is that Freshplace members meet with a Project Manager during their first visit, and then monthly, to discuss and set goals for becoming food secure and self-sufficient. Clients come up with their own goals that they want to work on, which are not imposed by the Project Manager. Nutrition education and a Cooking Matters course are also offered to memebers.

This program has benefitted from having an ongoing evaluation from its inception by a team from the University of Connecticut’s, Institute for Clinical and Translational Science headed up by Katie Martin PhD from the Department of Allied Health Sciences. Katie’s research background is in food security, community food security work, and food assistance programs.

Downloads are available here with the top level Freshplace Research Update as well as a Case Management in Food Pantries Research Brief. I spoke with both Katie and later with Foodshare’s CEO, Gloria McAdam to see what practices or ideas we could take from Freshplace.

 
Katie Martin

Katie, tell me how you came to be involved with the Freshplace project

They had been working for a few years on the notion of a food pantry that could address some of the underlying issues of poverty that were creating the need for food. I talked to them about evaluating this program and in 2009 I joined their advisory group, strategic planning group as we were concurrently developing the program and the evaluation.  Freshplace opened in July of 2010, and right from the beginning we’ve been conducting a randomized control trial of Freshplace where we recruit people from regular food pantries because we want to see how this intervention compares to these other traditional pantries. We randomized 100 into each group and have been tracking the same 200+ people for over a year now and will conclude our 18 month data collection in December.

What has the Freshplace group shown versus the control group in terms of effect on improving food security?

We’re in a very poor neighborhood in a poor city (Hartford) and half of all of the people we began the study with were experiencing significant hunger, cutting back the size of their meals or skipping meals because there isn’t enough food.

The bit the Hartford Tourist Board want you to see.

Over the year, Freshplace members were half as likely to remain in that category. We’ve seen increased food security and also increased self-sufficiency, which are both significantly higher than in the control group.

In the area of diet quality we’ve also seen significant improvement in fruit and vegetable consumption.

The one real challenge area is that we haven’t seen real declines in consumption of fat from snack and other unhealthy food. That means we still have some work to do.

How do you measure these areas?

We have been looking at three main outcomes:

FOOD SECURITY – For which we use the USDA food security module with its 18 questions,

SELF-SUFFICIENCY – For which we have been using the Missouri Self-Sufficiency Scale, which measures changes for 10 different indicators including income, employment, education, housing, transportation, physical health, mental health, child care.

QUALITY OF DIET – The consumption of fresh fruits and vegetables, fiber and also fat and snacks. For this, we’re using the Block food frequency questionnaire.

So, tell me a little more about Freshplace in action.

Clients can attend twice a month for food and once a month to meet with a project manager to discuss what areas they are interested in working on. Those goals are then reviewed in a supportive way.

That’s always kind of been an issue in terms of us demonstrating what we’re doing is improving food security because of the limited amount of a person’s total diet that is derived from a pantry’s food. The other unknown has been that we don’t really know how many different sites people are attending.  How did you deal with that in your study?

In our population, people are going chronically to different food pantries on average two to three times per week averaging up to four different pantry providers accessed every month.  I think a key piece that I think you write about beautifully in your blog is the notion of how food banks around the country are now starting to question how much longer they are going to be able to increase poundage and numbers of people served without significantly investing in preventative measures – whether health and nutrition education and empowerment  or the advocacy to change things. I’ve argued for a long time that hunger is about more than just food and that I think the data that we see nationally and we’re seeing at Freshplace is that even when people are going to multiple food pantries multiple times a week and they’re getting food and they know the system of how to engage in it to the best of their abilities, that it is still not enough to increase their food security. This is reflected by our food insecurity rates nationally really remaining untouched.  I think it’s time for a different way of approaching this issue.

What is the specific model of case management that they are using?

It’s based on the Stages of Change approach, coupled with motivational interviewing.

The idea is that we’re not telling folks the changes that they need to make, but working with them to determine what issues are most important in their life and what are the potential barriers that they encounter that are holding them back from reaching those goals. This type of model is used in some other types of work like HIV prevention, in trying to encourage people to have safe sex using that type of motivation and behavior change model.  We actually did a little bit of research through Foodshare of all of the partner agencies that receive food from the food bank to ask them whether they were providing case management in their pantry and what specific other services they provide just to get a handle on how unique or not unique Freshplace might be within the bigger field.  About half of the food pantries that responded said that they did offer some kind of case management, half did not.  But of the half who said they did, very few of them actually meet monthly and do a follow up. Most consider case management as giving a referral or a brochure with some other type of information.  This isn’t enough. A good Project Manager can be empowering when using motivational interviewing and in recognizing that people go through stages in their readiness to make changes in their life.  If we can engage in a relationship with clients where they trust us, we can have a dialogue where they know they’re coming back in a month and we’re going to do a follow-up with them and ask how they’re doing and what their issues are.

Obviously the food is an excellent motivator for people to return for the monthly interview, but how do people reach the point where they’re food secure enough to exit the program, or would anyone want to leave and turn down free food?

We always knew that we didn’t want this program to be another dependency program where people would stay on it for years.  We wanted this to be something that we could help give people a hand up and that they would want to and be able to move on. We spent some time really deciding what graduation from the program really means and giving clearer expectations so that when people come to Freshplace, they know from the beginning that there are expectations that we will offer a lot of support and services and programs, but you need to want this too so we’re going to meet with you and make sure that you’re making changes.  If you’re really just coming for the food, then I think right now we give maybe three to six months of that time to really monitor are they not making any progress towards their goals and if not, if they’re really just coming for the food, then there are other food pantries in the community that offer that.  So they’ll be discharged to allow other people to join the program.

There is currently a lively debate in the broader non-profit world about focusing all our attention on those who are able to improve and change their lives, because they are the ones that can deliver us the metrics of success that funders want. In the food banking arena, this would be ensuring the continued ability to feed all people; those with mental illness or who just can’t provide for themselves.  I think it is key to build in some avenue out for those who can’t or won’t or who are simply not ready to take on this wider change element. They would still be served to the best of our care and ability, but we wouldn’t waste their time and our money on these particular types of intervention resources.

Yes. I think we face a dichotomy in our country about the issue of hunger. When I describe the work that I do, people will often say, “We’ll always have hunger.”  Even though people don’t like the idea of people going hungry, there’s also this kind of acceptance that there will always be people in need. Now there are definitely those who fit into the category you just described, say those facing severe substance abuse, mental health issues, engrained generational poverty who need traditional food bank services.  But I would argue on the other side nationally there are millions of Americans right now who are food insecure and not sure how they are going to feed their family at the end of the week or the end of the month and I feel very uncomfortable with accepting that. I think from the bottom up we need to work with people and empower them and build those relationships so they can be ready to make changes, but from the top down we need to ensure that in our country that if people are trying their best to get a job or are working one or two jobs, they should be able to have a living wage where they should be able to go out and afford enough food for their family.

So this expanded group of Americans who are benefitting from our services, the 1 in 6. Aren’t a lot of this new group added by the recession able to look after themselves and might find the case management approach patronizing and disempowering? They might think that they just need a break or a few more hours work or a few more benefits. Can this group really benefit from the Freshplace approach?

I think they can. Those who have fallen on hard times need more than a bag of food. They need the ongoing support and link to a range of services rather than just short term food security. We can help them build their job skills to get a better job, and they can help us in our advocacy work to press for the policy changes that will help them long term.

With our own programs we’ve initially kept close to schools basically because that’s a place whereby we can tap into deeper more long term relationships with clients and build what we call their food literacy. However we’re now looking more closely at the thinking behind and impact of our more classic types of distribution. I think in the past the philosophy was to find a poor part of town and carpet-bomb the area with cans of food, hoping that this ‘shotgun’ approach would hit the right people and improve their lives. We did serve a bunch of people who really needed the help, and some who really didn’t need the help but weren’t foolish enough to turn down some free food. We certainly did little to change the long term health or prospects of either group. Do you think it is important to transition away from these traditional mass distributions? I mean it’s not like we have as much food available to us as we used to.

I think you’re right that so often we look at low income communities and say there’s so much need, there’s so much poverty, there’s so many problems we kind of throw our hands up and just say, “Well, let’s just provide food.”  I think a different approach is sorely needed, which says that these are communities that have assets and rich human and social capital, which If tapped, can do amazing things. We need to work with folks to find out why they’re struggling so much.  What are the barriers in their lives?  Again, it takes more time than simply giving food. And I think often Americans like the quick fixes.  Programs like Bridges out of Poverty (Watch out for an upcoming post on their work) are enabling people to really self-investigate what are the issues that are holding them back in their lives. But to truly be most successful, this requires the community as a whole to say ‘how do we look at the issue of poverty in our community and how are we all involved?’  That addresses employers and schools and the bigger picture which impacts all of us. Otherwise we will stick to our quick fixes and continue to spin our wheels.

Traditional food banking makes us feel great about charitable giving, but we’re not making an impact on food security or self-sufficiency or diet quality. That’s why Freshplace offers a different model, that if we can analyze it and find out what’s really working and how we can replicate it, then it could provide an avenue for a longer term approach to dealing with hunger. Clearly, this model is not going to be feasible for every food pantry. They might serve 500 people in a week, how could they possibly provide case management for 500 people in a week?  And I would say, you won’t, but I think that you could target a small segment of that group that you feel would be most ready to make these changes or people who would like to get off of that food pantry line. You could work with them and monitor their changes over time, so you would have that longitudinal data and with the expectation that hopefully six months from now they’re no longer in that food pantry line.

Some food banks may have the financial resources to hire a case manager and deal with issues that aren’t necessarily food related.  The challenge for other food banks is, ‘how do I partner with other organizations that have these skills or specialty to really provide a range of services that cover more of the spectrum of issues covered by the Self-Sufficiency screener?’  What kind of models do you think would work for that partnership?

My interest is in translational research, making sure that things are meaningful on the ground. An academic study is not as much use if other people can’t use this information.  One of the things that we did with Freshplace is to partner with the social work program at the University of Connecticut with the idea that many communities that already have food banks often probably will have some university or college setting that would have a social work program and those social work students need hours in the field of working.  They need that expertise and experience so that can be a way.  We’ve had two women who’ve come through the social work program who’ve worked with the paid case manager through Freshplace who are getting their hours towards their degree and I think that’s a model that other communities could use to partner with other existing programs in their area that wouldn’t necessarily require a lot of funding.

I then spoke with Gloria McAdam, CEO of Foodshare.

Gloria J. McAdam

Gloria, the results from Fresh Place are looking very promising. I understand that you are aiming to scale the program – are you just planning on providing your own case managers or cooperating with other nonprofits.

Our original vision with the Freshplace model was to be able to replicate it throughout our service area.  For example, in the City of Hartford, which is only 17 square miles, there are currently around 90 food pantries.  Since most of these pantries give out meager amounts of food and offer no other services, this structure forces clients to go from one pantry to another, just to put food on the table.  We believe that a much smaller number of pantries, probably 10-15, who operate on the larger scale that Freshplace does and provides these additional services, could serve people much more effectively.

We could do a better job of getting people the food they need for sustenance as well as providing additional services and supports that would move those families toward self-sufficiency.  Our next step with this project is a replication manual and to start identifying new partners for expansion.

In addition, we are considering the idea of hiring a case manager on Foodshare’s payroll who would rotate among a few smaller agencies to test whether case management can also work in smaller food pantries.  We are just in the thought phase of this idea – what would it look like, what would it cost, which agencies might be interested and where would the funds come from.

That’s great work Gloria, thanks to you and Katie for sharing and keep us informed as things progress.

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


The Backpack Program: Sacred Cow or Fatted Calf?

Everybody loves backpack.

It is one of the maxims of food banking.

BackPack provides emergency supplemental food assistance to children to ease hunger over the weekend. The backpacks (in reality plastic bags after the issue of single backpack at the beginning of the year) are full of single serve food items, typically containing protein items like tuna or peanut butter as well as snack bars, small cans of chili or franks and beans etc.

Contents of one Food Bank’s Backpack

As food banks have grown over the last decade, so has the volume of food passing through them and the funds they receive. This has resulted in many of them initiating major expansions of their backpack programs – our own organization included. The money for this is so easy to raise in the local community, because it presents such a readily understandable and direct solution to the issue of hunger for kids. (Try getting a buck for SNAP outreach, people). Packing the backpacks is also a great volunteer activity, giving corporate volunteers something to do beside freeze their ass off mindlessly sorting carrots in the warehouse. This is direct and visceral. I just filled a bag with food that will soon go directly to a kid.

This expansion of backpack has been heavily supported by Feeding America, both with a formalization of what contents are required to have a backpack program meet their guidelines and also with pass-through funding. This commitment continues with the recent study into backpack nutrition.

So why is the Foodbank of Santa Barbara County making very significant cuts in the numbers of backpacks provided for in our newly accepted 2013 budget?

Mr. Todd had a very creative idea for a food-related earned income strategy…

Is it because the CEO is some descendent of the Child Catcher in Chitty Chitty Bang Bang, determined to bring misery to the children of the land? Always a possibility.

Nevertheless, our reasoning is that backpack, despite its virtues does nothing to assist the people it serves in getting out of the situation they are in, so for us, that rung warning bells and meant the program had to come under considerable scrutiny.

Foodbank of Santa Barbara County Program Engine

Our mantra is that everything we do needs to achieve three things:

1. provide short-term hunger relief and nutritional benefit,

2. also provide long-term empowerment and education to help provide a pathway out of food insecurity and boost food literacy and

3. we have to find a way to make the initiative community driven (and therefore sustainable).

So, backpack probably logs a modest though unspectacular score for criteria 1. It logs a zero for criteria number two (I have seen the occasional glossy nutrition education pamphlet included in a backpack, doubtless paid for as one of the educational elements of a grant from a large corporation. Our work with this populace suggests that these sort of expensive and uninvolving attempts at education are quickly discarded.) And then for criteria three, it would probably get the healthiest score of all. There are plenty of people in the community who wouldn’t want the program to die and would provide cash and volunteer support.

With our goal to end hunger, rather than just ameliorate it at some supposedly acceptable level, this lack of effectiveness for criteria number 2 is a really serious issue. Hence our cuts to backpack in our overall program mix for children.

We believe these cuts will not affect those who need the program most, and will allow us to divert the funds (and more) to a major expansion of our award winning (have I mentioned this in the last five minutes) Healthy School Pantry Program  which we believe represents a far more impactful and long lasting nutritional intervention for our families.

Our research showed that many of the backpacks were just being provided for kids in after school programs that happened to be run in schools with a significant number of free and reduced meal students.

Master Maxwell Jorgensen. Butter would not melt…

The situation was highlighted for me, when my own stepson Max came back from his YMCA after-school program carrying a plastic bag of food from our Food Bank.  Obviously if you work in the food banking world, you are not taking home the mega bucks. Yet hopefully a backpack should be going to a family in greater need than that of the CEO of the Food Bank where the backpack originated from.

Many backpack programs go out through after school programs, but some also enter directly into the school environment. This originally came out of the hope that teachers would identify kids in need who would be the ones who would receive food. However the reality has been for many food banks, that teachers are often too busy to follow through with the admin side of having to do this, and it is logistically easier for the food bank to send a larger quantity of backpacks. We have also seen cases where larger and larger amounts of backpacks have been requested for wider distribution in lower-income schools to avoid stigmatization of those who most need help. This is an worthy consideration, but it also waters down the true intent of the program.

We did a survey of our backpack program, so that we could make sure we were basing our decisions on the real world situation rather than what we thought it might be. This survey showed that backpacks are very often shared with the children’s families, especially in a situation where a number of children in a family might be receiving a backpack. So whatever the more targeted approach that the backpack was designed for – specifically those in transitional living or homeless situations – it was increasingly being used as a simple supplement to the family diet. Plenty of those diets could benefit from supplementing, so there might be nothing wrong with this – if it weren’t for the issues of cost and nutritional value of the average backpack contents.

In Santa Barbara, our backpacks have always included fresh fruit (apples, oranges, stone fruit) or vegetables, yet we were still sometimes getting complaints from from visitors and volunteers about the quality of some of the food that went out in the backpacks.

True Confessions: These actually went out on one of our backpacks, may God have mercy on our eternal souls…

Obviously different volunteers have different perceptions of what constitutes suitable food for a child to eat. Some believe we should provide comfort to those in a tough situation by offering comfort food, whatever the ugly nutritional truth behind the bright shiny boxes. Others have a level of health zealotry such that anything we could provide would never be good enough. However I know (from my photographic proof above) that in the past, we have had  poor quality food go out in backpacks. Food that I would not give my own children to eat (which surely has to be the criteria for what we provide to other children). I have also seen backpacks serve as dumping grounds for inappropriate amounts of produce that we wanted to get out. The provision of fresh produce in backpacks is still provided in a minority of food banks nationally, and through my own visits to other food banks around the country, I have seen  all manner of borderline crap going out that may make the child’s nutritional situation worse.

Another (nameless) food bank’s  backpack. Pop tarts, chocolate milk, ritz crackers, popcorn and mac and cheese.  Not much here to grow a healthy child.

Packaging is another major issue. Feeding America requires backpacks in their programs to contain food items that should be able to be opened by a child without access to a can opener. (Does that mean we are building a generation that can’t even work a can opener?) As a result of this single ‘e-z open’ requirement, this program plays to the worst packaging excesses of the American food industry. Tiny amounts of food is entombed in containers that cost vastly more than the food they are there to protect. I should say, though, that when the zombie apocalypse comes, I’ll shotgun my way over to the backpack storage section of the food bank, because that stuff will still be in exactly the same state as the day it was incarcarated.

Remember your sensitivity training people: When someone walks into a food bank, you should never prejudge them as being either client or donor based on what they look like. However if they are shuffling with flesh hanging off and reaching for your throat, you really should consider making an exception…

We know that there is no individual child-owned solution to the nutrition challenges that kids face.  Backpacks can’t solve childhood hunger. The only solution is a family solution (supported by an adequate Federal safety net, of course).  Backpack is a short-term fix with no way to help the family provide better, more consistent food.

There is no doubt that there are many children who are in truly dire circumstances. They are caught in a family situation of serious deprivation, maybe as a result of parental addiction, mental issues or simply having the misfortune to be born to truly awful parents. These kids need all kinds of help and there is clearly a need for backpack in a situation where the child may have to source and prepare their own food on a regular basis. Everyone involved with emergency food has their own stories related to this kind of client need. People can sometimes better understand  this type of situation when I refer to something in the wider culture. The bestselling memoir, ‘The Glass Castle’ by Jeanette Walls (soon to be made into a movie, starring Jennifer Lawrence) is an example that I sometimes use. Jeanette Wall states plainly in the book that her earliest memory was ‘of being on fire’, and we’re not talking literally. As a borderline starving three-year old left to her own devices by ‘different’ parents, she was boiling up her own hot dogs, standing on a chair in front of the stove and her dress caught on fire. (On her return from hospital, when she went right back to doing the same thing again, her mother congratulated her for being brave and ‘jumping right back in the saddle.’)

So clearly, some kids can use every backpack they can get their hands on to ward off starvation. The problem I am trying to highlight is that we have a whole program structured to deal with this kind of situation, whereas the vast majority of backpacks are going to kids who are not in such a dire emergency, and so the backpacks act as a nutritional supplement for the family. This is a clear distortion and if that is the case, the contents of the backpacks, with their small amount of food,  don’t really provide a lot of nutritional benefit.

We are not the lone heretics in taking a long, hard look at backpack. In fact, an organization as close as our own PDO (Partner Distribution Organization – Definition: Food Bank that cannot qualify for membership of Feeding America, except by being partnered with a larger member organization. Note to Feeding America – Could we stop this second class citizen thing?)  Our PDO, San Luis Obispo County’s Food Bank Coalition, under the leadership of Carl Hansen, no longer provides any backpacks, because they do not feel it is a cost-effective way to make a significant dent in food insecurity, preferring to focus on larger distributions to families.

So enough with the whining, Erik. What are you, with your blah-blah-blah award winning program, and your nice Santa Barbara weather, actually doing to solve the problems you have identified?

Our short-term solution is to redouble our efforts to more effectively target backpack by focusing on maintaining supply to agencies and shelters dealing with homeless families and those who need the largest short-term interventions. Within the school setting, we are looking to shift our contact point to the counselors. They are typically seeing kids who are acting out or struggling, possibly as a result of nutritional issues. Rather than just dump a pile of food on them, we want to get close to these people, provide training and to building up a real relationship to the food bank. (Having a program for the whole school which brings big benefits, like Healthy School Pantry is a great place to build such a relationship from). We can then rely on the counselors to be more effectively as a conduit for teachers to keep a wider look out for kids in need.  This creates a whole host of distribution problems – remember, food banks are great at macro, not so hot at micro. So it may be individual school volunteers picking up small quantities of backpacks from a locally sited distribution center. Maybe backpacks get dropped off along with the standard other food items by an agency that is near to the school.). Will this more time consuming approach work better than the previous scattershot approach? We will have to see, but with less food around how can expect to keep to the strategy of throwing a lot of food at the community, confident that some will stick to those who need it most.  We are hopeful that the school counselors, who are already advocates for children, will view backpack as one more tool in their toolbox to be used appropriately with the right kids, and that other families might be referred on to more appropriate Foodbank programs like Kid’s Farmers Market, Pink and Dude Chefs Middle School cooking program or the Grow Your Own Way program to help people grow more of their own food.

Up until now, I would suggest that within the food bank network, the backpack program has been both a sacred cow and a cash cow. Both of those elements, combined with the challenges of shifting food and education resources to other less ‘quick fix’ channels means that the backpack program as a mass feeding effort, as opposed to a highly targeted program will remain with many food banks for the foreseeable future.

So, am I talking out of my pop-top can? Please join the discussion and leave a comment.