The Appalachian (F)armacy An initiative to improve Health outcomes of low income families RHAT 24 th Annual Conference Theme: Rural Healthcare Infrastructure: Vital to Population Health K. Munene Mwirigi, M.P.A., M.S. DrPH(c)
Introductions • Who do we have here today? • Name • County/region • Occupation/ area of practice • Why you come to this presentation
Introduction • What is Food Insecurity? • Why does food quality matter? • Food security and health • Farmacy Program • Recommendations and opportunities for the community • Summary
Food Insecurity “Access by all members of the household at all times to enough food for an active healthy life” • USDA food insecurity scale – “when a participant reports 3 or more food - insecure conditions on the survey” These includes - • Low food security- reports of reduced quality, variety, or desirability of diet • Very low food security- multiple indications of disrupted eating patterns and reduced intake Prevalence of food insecurity in the US 2001- 2017 USDA, Economic Research Service using data from U.S. Department of Commerce, U.S. Census Bureau, Current Population Survey Food Security Supplement.
Assessing for Food Insecurity • I’m going to read you two statements that people have made about their food situation. For each statement, please tell me whether the statement was often true, sometimes true or never true for your household in the last 12 months/ 1 month. 1. “We worried whether our food would run out before we got money to buy more.” 2. “The food that we bought just didn’t last, and we didn’t have money to get more.” A response of “often true” or “sometimes true” to either question = positive screen for Food Insecurity
Food Insecurity in TN Food insecurity and income level • In Tennessee, 14.5% (about 1 M) of the population was food insecure in 2015. (National 12.3%) 2016 Overall food insecurity in TN Counties with highest rates (>20%) Lauderdale, Lake, Hardeman, Haywood, & Shelby Feeding America. (2016). Food insecurity in Tennessee. Retrieved from http://map.feedingamerica.org/county/2016/overall/tennessee
D E O Food Access- T Farmers markets & F local stores E S O R H C M • Health & nutrition Food insecurity E literacy I I Local economy- • Case management A farmers and local • Improved care N A business L A L T Social cohesion N Nutrition & Health and interaction H Knowledge T S
Food insecurity and food quality • Food insecure households deploy coping strategies, such as seeking calorically dense and satiating foods that are often nutritionally inadequate. • Poor diet quality characterized by high consumption of empty calories and low consumption of fruits and vegetables. • Changes in dietary consumption contribute to negative physical and mental outcomes and an increased risk for disease. Holben, D., & Marshall, M. (2017) Position of the Academy of Nutrition and Dietetics: Food Insecurity in the United States. JAND, 117 (12).
Food insecurity and chronic illness • Food insecurity has a bidirectional relationship with chronic illness • Report by USDA ERS (2017) using NHIS data • Food insecurity is a better predictor of chronic illness than income. • Associated with all 10 chronic illnesses vs income with only 3. • hypertension, coronary heart disease, hepatitis, stroke, cancer, asthma, diabetes, arthritis, chronic obstructive pulmonary disease, and kidney disease • Food security status is also strongly related to the likelihood of chronic disease in general, to the number of chronic conditions reported, and to self-assessed health • Berkowitz et al. study (2014) NHIS Data • 1 in 3 chronically ill patients were unable to afford food, medications, or both • Food Insecure adults more likely to report cost related medication under use Gregory, C. A., & Coleman-Jensen, A. (2017). Food Insecurity, Chronic Disease, and Health Among Working-Age Adults. Berkowitz, S. A., Seligman, H. K., & Choudhry, N. K. (2014). Treat or eat: Food insecurity, cost-related medication underuse, and unmet needs. American Journal of Medicine , 127 (4), 303 – 310
Chronic illnesses in Tennessee • Chronic illnesses now account for 7 of the top 10 causes of death in the US. (2014) Tennessee ranks 45 th on the America’s Health Rankings • • Premature Death (years lost before the age of 75)- – about 1 per every 10 deaths (Ranks 43 rd ) • Rates in Tennessee – Obesity 35% (U.S. 30%) – Diabetes 13% (U.S. 10%) – Cardiovascular Disease 9% (U.S. 6%) – Hypertension 39% (U.S. 31%) United Health Foundation. (2018). America’s Health Rankings
Food Insecurity- Summary • Consequences – Affects food quality – Associated with medication underuse – Associated with poor health outcomes – Associated with chronic illness – Better predictor of chronic illness than income
What are your thoughts? • Do you resonate with any of this information? • How do you assess for food insecurity in your practice? Do you? • What are your thoughts on food insecurity as a risk factor for health?
Food Assistance Programs & Healthy Incentives Programs • We know all about SNAP, WIC • SNAP eligibility is at or below 130% of the federal poverty line- – 16,000 per year for 1 person and 33,000 for a household of 4 • SNAP lacks restrictions that promote purchase of healthy food items. • SNAP participants have lower food quality, lower fruits and vegetable intake and higher empty calorie intake compared to non-SNAP participants of the same income level • Healthy Incentives programs provide incentives to SNAP participants – To increase access and encourage purchase of fresh fruits and vegetables. – These programs use tokens or vouchers and are mostly found in farmers’ markets (Nguyen, Shuval, Njike, & Katz, (2014) The Supplemental Nutrition Assistance Program and Dietary Quality Among US Adults: Findings From a Nationally Representative Survey
The mechanism of Food Assistance Programs IOM (Institute of Medicine) and NRC (National Research Council). 2013. Supplemental Nutrition Assistance Program: Examining the evidence to define benefit adequacy. Washington, DC: The National Academies Press.
Why fruits and vegetables? USDA recommendations of about 2 cups per day of fruit and about 3 cups per day of vegetables • Very low consumption rates in Tennessee – Tennessee ranks 47th in Fruits and veggie consumption – Only 7% of the population meets the standard in TN – Even lower rates for low income households • Nutrient dense & Health outcome – Fruits and vegetables provide a variety of nutrients that improve the diet quality and improve health outcomes • Access and affordability – Fruits and vegetables are expensive and less available in rural areas. The State of Obesity. (2011). Fruits and vegetable consumption.
Food Insecurity Nutrition Incentives • FINI was created under the 2014 Farm Bill – Created to develop strategies to improve diet quality of SNAP participants by providing incentives for fresh produce – Provide 50/50 match grants to nonprofit and state/local government agencies – Programs provide point-of-sale incentives- e.g. coupons – Types of grants under FINI • FINI pilots: ≤ $100,000 over ≤ 1 year • FINI projects: ≤ $500,000 over ≤ 4 years • FINI large scale projects: ≥ $500,000 over ≤ 4 years – Examples include AARP foundation, Wholesome wave • 2018 Farm Bill has not yet been passed. • Point-of-sale incentives – Currently provide incentives for fresh fruits and vegetables – Emphasize utilization of farmers markets – Improve the local economy and support local farmers
Appalachian Farmacy • Farmacy initiation – Awarded a FINI pilot grant for $100,000 – Started in July 2017 • July to October- Farmers markets • November to March at Food City locations • Farmacy Aims: – Increase the purchase and consumption of locally produced, fresh fruits and vegetables at Washington County farmer’s markets by providing vouchers and nutrition education
Multi-Partner!! • Food Insecurity Nutrition Incentives Grant – Appalachian Resource Conservation & Development Council (ARC&D) – Appalachian Sustainable Development (ASD) • Evaluation – ETSU College of Public Health • Implementation sites – Johnson City Community Health Center (CON/JCCHC) – Johnson City Senior Center (JCSC) – Jonesborough Senior Center (JBSC) – 3 Farmers Markets – Food City (produce section only) • Nutrition classes – University of Tennessee Extension (UT) Washington County
Appalachian Farmacy • Free fruits and vegetable vouchers given as prescriptions • Coalition team met monthly Health Nutrition Vouchers Redemption Assessment classes Monthly $28- $112 Farmers JCCHC UT Extension depending on Market Senior centers household size & Food City*
Evaluation design • Mixed methods approach • Quantitative- Survey – Baseline – Midpoint – after Farmer’s markets closed – 6 months • Qualitative – Intercept interviews (n=22) – 2 focus groups (n=11) • Thematic analysis • Data analysis on SPSS
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