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BY: SUSAN BRIDLE-FITZPATRICK, PhD

Illustration by Larry Moore

"Because of the high prevalence of obesity in our community, we took a close look at healthy eating issues in our community health needs assessment. We wanted to know the social determinants of health, and we wanted to address food insecurity, access to healthy foods and healthy living. That was just a high priority."

— Hospital community benefit director, Northeastern U.S.

An ever-increasing body of research demonstrates that social and environmental determinants of health — factors such as income, employment, safe housing, healthy food, clean water and air, education and neighborhood conditions — exert a powerful influence on health.¹

In the United States, the leading causes of death and largest sources of health care expenditure are linked to food and diet: diabetes, heart disease, stroke and some types of cancer. Growing prevalence of obesity has put millions of Americans at increased risk for chronic health conditions as well as poorer mental health and reduced quality of life. Low-income and minority populations are disproportionately affected, with obesity prevalence among black and Latino adults at 47 percent compared to 38 percent among white adults and prevalence among black and Latino children at 22 percent and 26 percent respectively, compared to 14 percent among white children.^{2, 3}

At the same time, 1 in 8 individuals and 1 in 6 children live in households that face food insecurity, or the lack of consistent access to adequate food for an active, healthy life.⁴ Food insecurity is associated with a higher risk of obesity and diet-related chronic diseases, including diabetes and hypertension. Food insecurity may put people in the position of making trade-offs between healthy food, medicine and other essential needs. One Feeding America study found that 66 percent of food bank client households choose between paying for food and medicine or medical care each year, while 55 percent choose between paying for food and housing. Food insecurity is associated with poorer management of health conditions and greater health care costs, including avoidable emergency department visits.⁵

HEALTHY FOOD ACCESS IS A VITAL SOCIAL DETERMINANT OF HEALTH
The good news is that hospitals and health systems are working to identify and address social determinants of health in their communities — particularly food insecurity and lack of affordable access to fresh, healthy foods. Research from a national study conducted by Health Care Without Harm — Community Benefit and Healthy Food: A National Assessment, published in 2018 — shows growing interest by hospitals to address healthy food access and healthy eating as part of their community benefit/community health programs.⁶ Health Care Without Harm is an international coalition that works closely with Practice Greenhealth, the leading nonprofit membership and network organization for environmentally sustainable health care, serving more than 1,200 hospital members throughout the United States. Hospitals around the country are embracing the fact that affordable access to healthy food is critical not just to preventing and treating diet-related health conditions, but also to building thriving communities, strong local economies and sustainable food systems.⁷ Community benefit represents a powerful opportunity to promote community well-being through healthy food.

UNDERSTANDING FOOD-RELATED HEALTH NEEDS AND OPPORTUNITIES
Health Care Without Harm's comprehensive study revealed important trends in hospitals' community benefit activities to understand and address food access and diet-related health needs in their communities.⁸ The study's nationally representative survey of hospital community benefit directors found that in their most recent community health needs assessment (CHNA), 71 percent of hospitals identified obesity as a health issue in their communities.⁹ Other selected health needs identified in CHNAs include:

• 40 percent–Diabetes

• 45 percent–Other diet-related diseases

• 13 percent–Food insecurity or healthy food access

• 22 percent–Poverty, economic security or unemployment

More and more hospitals — 57 percent of survey respondent facilities — are collecting information about the quality of community food environments, such as the prevalence of U.S. Department of Agriculture "food deserts," in their assessments. Data on diet-related behaviors, such as fruit and vegetable consumption, was included in 40 percent of CHNAs.¹⁰

Perhaps even more important, hospitals are including community organizations that work on food access and food system issues in the CHNA process. Forty-five percent of hospitals included at least one food-related organization, such as food banks or food policy councils, on their CHNA steering committees.¹¹ Engaging community food organizations in the CHNA process leads to a more nuanced understanding of food-related health needs as well as resources and opportunities to effectively address these needs.

HOSPITAL COMMUNITY BENEFIT PROGRAMS PROMOTE HEALTHY FOOD ACCESS AND HEALTHY EATING
Hospitals across the country are participating in diverse community benefit programs to address obesity, healthy eating and diet-related health conditions. Diet and nutrition education and exercise promotion are the most common interventions. However, health professionals understand that although they may encourage patients to eat five servings of vegetables and fruits each day, if families are struggling with food insecurity, it will be difficult to adhere to those recommendations. Working with community partners, many health systems are making healthy food and healthy eating more accessible, convenient, affordable — and even fun.

Screening for Food Insecurity
When health care providers assess patients for food insecurity, they can help overcome the stigma of not having consistent access to food. They can identify a vulnerable target population, tailor clinical care to real patient needs, help reduce the prevalence of food insecurity and its effects on the community, and potentially reduce health care costs by reducing preventable emergency department and provider visits.

Health systems such as Providence Medical Group, based in Oregon, use a "screen and intervene" strategy. It includes screening for food insecurity (for example, by using the Hunger Vital Sign two-question food insecurity screening tool), identifying food insecurity in patients' electronic medical records, and connecting food-insecure individuals and families to food resources.

Food Banks and Pantries
Food banks play a central role in the network of national, regional and local organizations working together to address the needs of food insecure communities across the nation. Hospitals can support food banks and pantries in their efforts to provide fresh, healthy food for their clients. From hosting food pantries onsite to offering diet and nutrition education to investing in refrigerators, hospitals are partnering with food banks to improve community food security and health.

St. Vincent Randolph, a critical access hospital in Winchester, Indiana, donated funds to purchase refrigerators for the Community Food Pantry to support sourcing and providing clients with fresh produce. The Winchester Area Community and Churches Food Pantry also is located on the St. Vincent Randolph campus.

Fruit and Vegetable Incentive Programs
Fruit and vegetable incentive programs, such as Double Up Food Bucks and "prescriptions" for produce, reduce economic barriers that some families face when purchasing fresh, healthy foods. Hospitals are partnering with programs that increase produce purchasing power by doubling the value of Supplemental Nutrition Assistance Program resources or by providing prescriptions with vouchers that can be redeemed for fresh fruits and vegetables.

Seattle Children's Hospital in Washington has provided grant support to help fund Fresh Bucks Seattle, the city's fresh produce incentive program. Program evaluators found that 89 percent of surveyed participants reported eating more fruits and vegetables because of Fresh Bucks.

Farm-To-School
Farm-to-school experiences are associated with students' increased consumption of fruits and vegetables. Farm-to-school activities range from buying food from area farmers to serve at schools, to farm field trips, to hands-on learning in a garden, cooking demonstrations and integration of food-related information into classroom curricula. Hospitals can enhance farm-to-school activities, which support students' health while strengthening local and regional food systems.

Orlando Health, a health care network in central Florida, created the Healthy Living Garden at Orange Center Elementary in that city to interest and teach students about food, health and nutrition. Located in an area where exposure to fresh, healthy food is limited, the garden gives 345 students access to fresh produce and the opportunity to participate in garden-based health and education activities.

Meal Programs
Summer, after-school and weekend meal programs give low-income children vital access to nutritious foods when school is not in session. The USDA's Summer Food Service Program and the Child and Adult Care Food Program provide funding to state agencies that coordinate with locally based sponsors to operate programs. Hospitals can play key roles, whether operating on-site meal programs or supporting other efforts in their communities.

Reading Hospital in Pennsylvania was a partner in an initiative to create a summer meal site at a public housing complex, next to the Berks Community Health Center, a federally qualified health center. The hospital contributed funding to upgrade a picnic pavilion to meet requirements for meal program sites. The meals include fresh local produce, and the clinic offers free screenings as well as wellness and nutrition programs to children and families.

Farmers Markets and Mobile Markets
Hospitals throughout the United States host farmers markets to create healthier community food environments and promote healthy eating behaviors. Farmers markets in all 50 states now accept SNAP benefits; between 2012 and 2017 farmers markets nationally saw a 129 percent increase in the number of SNAP authorized sites and a 35 percent increase in SNAP redemptions.¹²

Florida Hospital (now AdventHealth Orlando) awarded a grant to Fresh Stop — a fruit and vegetable market on wheels — to outfit a bus with special refrigerated racks for fresh vegetables and fruits. The Fresh Stop bus delivers fresh, healthy food to 16 locations in food desert neighborhoods. Supported by the central Florida community, the service sells produce at discounted prices, provides nutrition education and even offers cooking tips.

Community-Supported Agriculture
Community-supported agriculture, or CSA, programs provide members with a box or a "share" of fresh, local fruits and vegetables and other farm products that are in harvest at the time of weekly distribution. CSA programs not only can increase access to fresh, healthy foods for vulnerable households, but they also can support farmers and keep food dollars circulating in the local economy.

Since 2013, Presbyterian Healthcare Services, a health care system in New Mexico, has provided funding to subsidize La Cosecha CSA shares to ensure that the CSA is affordable for low-income families without jeopardizing the ability of the farmers and farmworkers to earn a fair wage. Each week the CSA shares are accompanied by a nutrition education handout written in English and Spanish that includes information about the farms as well as nutrition guidance, kid-friendly recipes and storage tips related to that week's produce.

Food Policy Advocacy
A food policy council is a group of stakeholders that addresses food-related needs within a designated region. Food policy councils include a diversity of sectors and industries as well as public, private and nonprofit organizations. Their primary goals align closely with those that health care institutions also care about deeply: addressing food insecurity, healthy food access, regional economic development and environmental sustainability, among others.

St. Joseph Mercy Ann Arbor Hospital in Michigan has a seat on the Washtenaw County Food Policy Council, which has joined other local councils to successfully advocate for an expansion of state funding for the 10 Cents a Meal for School Kids & Farms program. This pilot program provides schools with up to 10 cents per meal in match funding to purchase and serve Michigan-grown fruits, vegetables and legumes. The program for the 2016-17 school year provided 48,000 students in 16 school districts with 49 different Michigan-grown foods from 86 farms.

Healthier Corner Stores
Healthier corner store initiatives increase and promote healthy food options in small retail settings. Hospitals can partner with public health departments and local agencies to enhance these efforts by providing funding, training and resources to help store owners stock and promote healthy food choices.

Montefiore Medical Center's Healthy Store Initiative works with Jetro, the primary supplier for New York City bodegas, and corner stores in neighborhoods with high rates of obesity. Stores receive promotional materials and technical assistance on how to promote healthy items and a Shop Healthy NYC designation when they achieve program goals. Montefiore also partners with community organizations on "Adopt a Shop" activities for nutrition education and to drive demand for healthy products.

For more information on healthy food access and healthy eating efforts, the "Delivering Community Benefit: Healthy Food Playbook" provides practical guidance for hospitals interested in working with community partners to implement these and other healthy food programs, including examples and lessons learned from across the U.S.¹³

TRIPLE WIN STRATEGIES
When developing food programs, strategies can be integrated to accomplish three complementary goals: improve access to healthy, affordable food; support economic and workforce development in low-income communities; and strengthen local and sustainable food systems.

Interventions that address healthy food access with this kind of "triple win" strategy address social and environmental determinants of health as part of a transformative community development framework. Initiatives such as community-supported agriculture, fruit and vegetable prescription programs, mobile farmers markets, and farm-to-school programs can increase access to healthy and affordable food while creating jobs in underserved communities and localizing the food economy.

Community benefit is only one of many ways that hospitals and health systems invest in the health and well-being of their communities. As anchor institutions — large, nonprofit organizations that, once established, tend to remain rooted in place — hospitals are increasingly recognizing their "anchor mission" to harness their significant economic and other resources to address social and environmental determinants of health in the communities they serve.

Anchors in Resilient Communities is a multi-sector collaborative coordinated by Health Care Without Harm and Emerald Cities Collaborative to leverage the assets and capacities of anchor institutions and community-based partners in San Francisco East Bay, with a focus on strengthening the health, wealth and resilience of communities of color and low- and moderate-income residents. The collaborative's initial project, My-Cultiver, is focused on building a healthy regional food system and strengthening the local food economy. My-Cultiver aims to produce 200,000 healthy and locally sourced ready-to-eat meals per day to distribute to hospitals, schools and other institutions through long-term contracts. The initiative also will create union jobs and cooperative ownership opportunities.

Kaiser Permanente plays a unique role in supporting the development and implementation of ARC and My-Cultiver by providing community benefit and other investments and purchasing commitments. Kaiser Permanente also serves on the ARC advisory committee and on several working groups.

WHY PARTNERSHIPS MATTER

"Hospitals are not going to fix all the problems that we identify in our needs assessments. It's not something that's going to be remedied solely by hospitals or solely by your county public health department. It truly does involve collaboration. There are a lot of really great resources that currently exist in the community. It's about raising awareness of those resources and connecting the dots. I'm very interested in designing sustainable efforts, and we have found that it doesn't necessarily cost a lot of money to be a strategic partner."

—Hospital community benefit director, Western U.S.

Health care facilities can't improve the social and environmental determinants of health alone. Such change requires a collaborative, community-wide effort. In Community Benefit and Healthy Food: A National Assessment, community benefit professionals emphasized their reliance on partnerships with community organizations not only to understand food-related health needs in their communities but also to design, implement and evaluate successful healthy food programs. Collaboration with community partners is essential to:

• Reveal gaps, areas of need and opportunities to strengthen current assets
• Align with existing community efforts or bring groups and organizations together for greater coordination and synergy
• Develop more effective and appropriate strategies and approaches by consulting experts in the field with experience addressing food system and equity issues
• Strengthen relationships to improve reach, impact and long-term sustainability of efforts
• Avoid duplication of programs and services

In addition, there are numerous ways that hospitals can provide community benefit support for healthy food access programs, including contributing staff time and expertise, other in-kind contributions and financial resources. Health Care Without Harm's research identified nine common role categories that hospitals are playing in support of healthy food access programs:

• Provide grant support
• Provide use of hospital facilities
• Conduct food insecurity or other health screening
• Conduct nutrition, food or cooking education
• Provide staff or financial support for program evaluation
• Provide staff support for grant writing or securing sustainable funding of community benefit initiatives
• Manage or coordinate a program or community collaboration
• Participate in a community collaboration
• Advocate for healthier food policies

The healthy food playbook's guidance brief on "identifying community partners" can help facilities identify community organizations that can be critical partners in healthy food access initiatives, while its resources on "hospitals' community benefit roles" discusses diverse roles hospitals can play, with examples.¹⁴

CONCLUSION
Hospitals around the country are embracing the fact that affordable access to healthy food is critical not just to preventing and treating diet-related health conditions, but also to building thriving communities, strong local economies and sustainable food systems.

Still, an obstacle for many hospitals to investing in improving social determinants is the challenge of measuring return on investment in terms of reduced health care utilization and cost. Some hospitals across the country are beginning to identify these positive impacts but need more time to test and evaluate programs. While it is challenging, securing continued investment in social determinants of health requires that health care organizations collaborate with community partners to demonstrate impact.

A broader, longer-term approach to identifying social return on investment—in which socio-economic and environmental results are assessed together with traditional financial measures — can be advanced through multisector collaborations in which schools, health care organizations, social service providers and other community organizations coordinate services and share data.¹⁵ Such collaboration can assess diverse impacts of social determinants of health interventions over a longer time period, potentially capturing improved health status, higher high school and college graduation rates, and increased employment and earnings in underserved communities.

Community benefit professionals can tell the story of the impact of community health improvement initiatives in terms of multiple forms of return on investment. This also can include a more engaged health care workforce. Staff members at hospitals that invest in social determinants of health may feel more inspired, committed and engaged in their work — proud and enthusiastic to be part of a health care organization that makes a difference in the community.

SUSAN BRIDLE-FIZPATRICK is principal at Healthy Food Strategies, a research and policy analysis consulting firm; adjunct faculty at the University of Denver; and former senior researcher at Health Care Without Harm.

NOTES
Research and resources developed by Health Care Without Harm's national Healthy Food in Health Care program, with support from the Robert Wood Johnson Foundation, are the basis for much of this article. Research assistance was provided by Jessica O'Toole, Dan Myers, Morgan Fleming, Betsy Skoda and Nicki Milgrom. The Healthy Food in Health Care program harnesses the purchasing power and expertise of the health care sector to promote a healthy, equitable and sustainable food system. More information at healthyfoodinhealthcare.org.

1. Hyojun Park et al., "Relative Contributions of a Set of Health Factors to Selected Health Outcomes," American Journal of Preventive Medicine 49, no. 6 (December 2015): 961-69.
2. Centers for Disease Control and Prevention website, "Adult Obesity Causes and Consequences," www.cdc.gov/obesity/adult/causes.html and "The Health Effects of Overweight and Obesity,"www.cdc.gov/healthyweight/effects/index.html.
3. Craig M. Hales et al. "Prevalence of Obesity Among Adults and Youth: United States, 2015–2016," NCHS Data Brief, no. 288. Hyattsville, MD: National Center for Health Statistics. 2017, www.cdc.gov/nchs/products/databriefs/db288.htm.
4. "Map the Meal Gap 2018," report on the Feeding America website, www.feedingamerica.org/sites/default/files/research/map-the-meal-gap/2016/2016-map-the-meal-gap-all-modules.pdf.
5. "Hunger in America 2014," report on the Feeding America website, http://help.feedingamerica.org/HungerInAmerica/hunger-in-america-2014-full-report.pdf.
6. "Community Benefit and Healthy Food: A National Assessment," report on Health Care without Harm's website, https://foodcommunitybenefit.noharm.org/research-reports/community-benefit-and-healthy-food-national-assessment. This assessment included a representative survey of community benefit directors at private, tax-exempt general hospitals, a review of surveyed hospitals' community health needs assessments and community benefit implementation strategies, and over 100 in-depth interviews. The research examined the hospital community benefit landscape and identified promising practices to promote affordable access to healthy food and healthy eating to address risk of diet-related health conditions.
7. "Toward a Healthy Sustainable Food System," American Public Health Association website, https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/12/34/toward-a-healthy-sustainable-food-system.
8. "Community Benefit and Healthy Food: A National Assessment."
9. "Community Benefit and Healthy Food: A National Assessment."
10. "Delivering Community Benefit: Healthy Food Playbook," on the Health Care Without Harm website, https://foodcommunitybenefit.noharm.org/. The playbook is a suite of resources to support hospital community benefit professionals and community partners in developing community health interventions that promote healthy food access and healthier food environments. "Data Sources to Assess Food Access, Environments, and Behaviors in CHNAs" in the playbook is a practical guide to useful data sources, https://foodcommunitybenefit.noharm.org/resources/community-health-needs-assessment/data-sources.
11. See the guidance brief "Engaging the Community to Understand Food Needs" in the playbook to learn more, Health Care Without Harm website, https://foodcommunitybenefit.noharm.org/resources/community-health-needs-assessment/engaging-community-understand-food-needs.
12. "Comparison of SNAP Authorized Farmers Markets FY2012 to FY2017," U.S. Department of Agriculture website, https://fns-prod.azureedge.net/sites/default/files/snap/SNAP-Farmers-Markets-Redemptions.pdf.
13. "Delivering Community Benefit: Heathy Food Playbook."
14. "Delivering Community Benefit: Healthy Food Playbook."
15. "Social Return on Investment," Innovation Center Issue Brief (American Public Human Services Association, May 2013), https://33igt8427g0w69zms33dqm48-wpengine.netdna-ssl.com/wp-content/uploads/2014/06/Social-Return-on-Investment-Brief.pdf.