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.


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

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