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Food Insecurity in Indian Country:A Case Study ApproachKelli Begay, MS, MBA, RDNDivision of Diabetes Treatment and PreventionIndian Health ServicePatty Keane, MS, RDNPrevention Research CenterUniversity of New Mexico

Food Security DefinedLabelFormerly known asDefined asHigh Food SecurityFood SecurityNo reported indications of food-accessproblems or limitationsMarginal FoodSecurityFood Security Low Food SecurityFood insecurity withouthunger Very Low FoodSecurityFood insecuritywith hungerOne or two reported indications –typically anxiety over food sufficiencyor shortage of food in the houseLittle or no indication of changes indiet or food intakeReports of reduced quality, variety, ordesirability of dietLittle or no indication of reduced foodintakeReports of multiple indications ofdisrupted eating patterns and reducedfood intakeSource: USDA Economic Research Service: -security.aspx#rangesDivision of DiabetesTreatment and Prevention2

Food Insecurity in US –Overall 2015Source: http://map.feedingamerica.orgDivision of DiabetesTreatment and Prevention3

Food Insecurity in US –Children 2015Source: http://map.feedingamerica.orgDivision of DiabetesTreatment and Prevention4

Food Deserts in Indian CountryLocation of food deserts and AI reservations in contiguous USOrange food desertGreen reservation bordersBrown overlapSource: Food desert by Census tract: US Department of Agriculture, Economic Research ServiceDivision of DiabetesTreatment and Prevention5

Understanding Food InsecurityRisk FactorsMore Likely Financial At the end of the month Low, inconsistent or lost income SNAP or income may have run out Recent job loss or reduction in hours Important to consider when taking a Inadequate SNAP allotment or accessdiet historyto government food programs Holiday seasons Senior citizens Birthdays, life-cycle rituals Single-parent homes Drug and alcohol dependency Uninsured or underinsured with amedical illness Feast Days Ceremonies Summer Seasonal bills Competing housing and medical costsDivision of Diabetes Treatment andPrevention6

Health Impacts of Food Insecurity (1)Children and Adolescents Chronic health/behavior issues Asthma Iron-deficiency anemia in infants and toddlers Greater chance of being hospitalized Greater developmental risk Low birth weight Higher anxiety and depression Suicide in adolescentsDivision of DiabetesTreatment and Prevention7

Health Impacts of Food Insecurity (2)Adults DiabetesAsthmaCardiovascular diseaseCancerObesityDepression and mental illnessChronic/toxic stressMedication underuseTobacco useExposure to violenceDivision of DiabetesTreatment and Prevention8

Cycle of Food Insecurityand Chronic Disease Hilary K. Seligman, MD and Dean Schillinger, “Hunger and Socioeconomic Disparities in ChronicDisease,” The New England Journal of Medicine 363 (2010): 6–9 http://www.nejm.org/doi/full/10.1056/NEJMp10000729

Policy, Systems, and Environmental(PSE) Change ApproachesSupporting healthy eating patterns in multiple settings,from home to school to work, to the communities in whichpeople live, learn, work, shop, worship, and play Policy is a written statement of an organizational position,decision, or course of action. Ideally policies describeactions, resources, implementation, evaluation, andenforcement. Systems changes are unwritten, ongoing, organizationaldecisions or changes that result in new activities that alterhow the organization or network of organizations conductsbusiness. Environmental includes changes to the built or physical,economic, social, normative or message environments.Division of DiabetesTreatment and Prevention10

Healthy Eating for Strong Native CommunitiesDivision of DiabetesTreatment and Prevention11

School and Early Care and Education(ECE) Settings National School Lunch Program School Breakfast Program Child and Adult Care Food Program Summer Food Service Program Fresh Fruit and Vegetable Program Initiate Farm to School Program Enact policy to remove all unhealthy options from vending machines Offer healthy breakfast, lunch, and after-school snacksDivision of Diabetes Treatment andPrevention12

Community Center Supplemental Nutrition AssistanceProgram (SNAP) Food Distribution Programon Indian Reservations (FDPIR) SNAP-Ed Older Americans Commodity Supplemental Food Assistance Program Congregate Dining Home-delivered Meals Offer healthy options in vending machines. Host events featuring Indigenous foods. Work with kitchen management to make Elder Nutrition Programmeals healthy and tasty.Division of Diabetes Treatment andPrevention13

Community Garden Provide education on therole of food in Indigenousculture and medicine. Create space for allgenerations to connectwith traditional-foodsknowledge.Division of DiabetesTreatment and Prevention14

Farmer’s Market Install EBT system toaccept SNAP and WICbenefits. Waive vendor fees forIndigenous producersand assist withlicensure.Division of DiabetesTreatment and Prevention15

Dance Grounds Provide incentives to vendors for offering healthyoptions and posting nutrition information for allitems. Encourage bringing healthy dishes to communitygatherings.Division of DiabetesTreatment and Prevention16

Natural Resources and Produce FarmNatural Resources: Offer opportunities forskill building intraditional hunting andgathering practices. Include Indigenousfoods in commodityprograms.Produce Farm: Offer youth training tosupport developmentof farming, leadership,and job skills. Supply foods toschools, stores, andother tribal programs.Division of Diabetes Treatment andPrevention17

Food Retail Enact policy requiring healthy advertising andmarketing at checkout area. Increase taxes on unhealthy options anddecrease taxes on healthy options.Division of DiabetesTreatment and Prevention18

Tribal Council and Government Center Apply a Health in All Policies (HiAP) framework todecision-making policies. (HiAP is an approach to tribal policy that weighs the potentialhealth impacts of decisions, seeking to avoid harmful healthimpacts and improve community outcomes.) Enact a tribal health and wellness policy. Support community health and wellness coalition orcommittee.“Right to healthy and culturally appropriate food produce through local,sustainable ways and the right of people to define their own food andagriculture systems”Division of DiabetesTreatment and Prevention19

Clinic Offer culturally appropriate nutritionalcounseling, including breastfeeding education. Initiate fruit and vegetable prescription programwith vouchers redeemable at stores andfarmers market.Division of DiabetesTreatment and Prevention20

Meet the Bird FamilyDivision of Diabetes Treatment andPrevention21

Michelle 44 years old Family history of heart disease, diabetes Presents to clinic with frequent headaches Blood pressure is 150/90 Doctor recommends lifestyle changes Referral to Health Educator/Dietitian/Nurse Works as a home health aid Three children (ages 4, 8, 14) Recently separated from husband, moved in with mother Recent reduction in work hoursDivision of DiabetesTreatment and Prevention22

Food Insecurity Assessment Tool andResource List Produced by the IHS Division of Diabetes Treatment and Prevention, 2015 Available essTool.pdf The following is a sample from the form:To help your patients and clients improve their health, it is important to understand foodinsecurity and provide them with resources to get more healthy food.When patients/clients and their children cannot get enough healthy food, they have foodinsecurity. They: Are at greater risk for being emotionally distressed. Eat less expensive foods which are often unhealthy. Have little choice over what kinds of food to buy or receive for free, making it difficult or impossible to eatbalanced meals. Have periods when they don’t eat, then overeat when food is available. If they have diabetes, this makes itvery difficult to manage blood sugar. Have a greater risk for being overweight or obese. Are more likely to get diseases like diabetes.Division of DiabetesTreatment and Prevention23

Screening1. Within the past 12 months, we worried whether ourfood would run out before we got money to buymore.2. Within the past 12 months, the food we bought justdidn’t last and we didn’t have money to get more.Answer Options: Often TrueSometimes TrueRarely TrueNever TrueIf the answer is either “Often True” or “Sometimes True”for either statement, it is likely that the person isexperiencing food insecurity.Division of DiabetesTreatment and Prevention24

Z59.4Event capture: Lack of adequate food and safe drinkingwater Billable/specific ICD-10-CM code that can beused to indicate a diagnosis for reimbursementpurposes.Division of DiabetesTreatment and Prevention25

What you don’t see Division of DiabetesTreatment and Prevention26

Ella – Michelle’s Mom 72 years old Active in community Attends Senior Center fitness classes Low monthly income from social security benefits Food budget has been impacted due to recentdeaths in community She’s concerned about how she’s going to takecare of her daughter and her daughter’s family The fitness specialist notices that Ella has adecrease in energy during classes.Division of DiabetesTreatment and Prevention27

Michelle’s ChildrenJames 14 years old Plays JV basketball Trying to make new friends The coach notices that James doesn’t have snacks or money for food duringaway games.Max 8 years old Attends Boys & Girls Club Interested in community garden The B&G Club staff see Max take extra snacks, especially on Fridays.Mariah 4 years old Attends Head Start program Quiet and shy Mariah regularly asks for seconds and thirds.Division of DiabetesTreatment and Prevention28

What do you do?Division of Diabetes Treatment andPrevention29

Possible Interventions – Ella(Michelle’s Mom) Fitness Specialist: Check in with her privately to see howthings are going at home Ask about her food situation and if therehave been any changes in her food budgetor meals Connect her with a food advocate, such asa dietitian, nurse, health educator, orCommunity Health Representative (CHR)Division of DiabetesTreatment and Prevention30

Possible Interventions – MichelleFood advocate: Connect her with food resources inthe community Reduced or free meals application forkids’ school meals Supplemental Nutrition AssistanceProgram (SNAP) Benefits Food Distribution Program Clinic Food Pantry Tribal Programs Local Food BanksDivision of DiabetesTreatment and Prevention31

How do you begin to identifythe layers of resources?32

Tools for Educators and Clinicians Where to Get Food Assistancein This Community form Second page of the Food InsecurityAssessment Tool and Resource List Download essTool.pdfDivision of DiabetesTreatment and Prevention33

Food Assistance Sheet Tips Keep sheet updated Normalize the situation Get to know internal and external resources Collaborate with local programs Tribal programs Extension programs Food Distribution ProgramsDivision of DiabetesTreatment and Prevention34

Emerging ApproachesMEANS DatabaseMatching Excess and Need for StabilityDivision of DiabetesTreatment and Prevention35

How MEANS Works An online platform and app for food pantries and the donors Donors: List a donation Food Banks and Pantries: Get notifications on nearby fooddonations Claim and pick up food when possible, otherwise ignore the alerts Learn more at https://www.meansdatabase.com/Division of DiabetesTreatment and Prevention36

Addressing Food Insecurity:A Toolkit for Pediatricians Prepare: Educate, train, follow AAP recommendations, incorporatescreening info, show sensitivity Screen: Use the AAP-recommended Hunger Vital Sign Intervene: Administer appropriate interventions, connect patients toresources, document and track interventions, support advocacy andefforts to end childhood food insecurity Learn more and find tools at http://frac.org/aaptoolkit.Division of DiabetesTreatment and Prevention37

Federal Nutrition Programs andEmergency Food Referral ChartLearn more at http://frac.org/aaptoolkitDivision of DiabetesTreatment and Prevention38

Farm Bill 2018 SNAP and SNAP-EdExpanded Food and Nutrition Education Program (EFNEP)Food Distribution Program on Indian Reservations (FDPIR)Native Farm Bill rm-bill-coalition/ Academy of Nutrition and islation/alllegislation/farm-billDivision of DiabetesTreatment and Prevention39

Resources First Nations Nourishing Native Foods & lth American Indian Cancer Foundation, Healthy Native nativefoods Seeds of Native Health: http://seedsofnativehealth.org/ American Academy of Pediatrics Food Insecurity Toolkit:http://frac.org/aaptoolkit Feeding /Division of DiabetesTreatment and Prevention40

diet or food intake. Low Food Security. Food insecurity without hunger Reports of reduced quality, variety, or desirability of diet Little or no indication of reduced food intake. Very Low Food Security. Food insecurity : with hunger. Reports of multiple indications of disrupted eating patterns and reduced food intake