[Dr. Konstan] It's uh 12:00, so we're going to get started. If I can have the There you go. Great. Uh welcome to our uh Cardi-OH uh webinar, identifying and addressing uh food insecurity in the medical setting. I'm Dr. Michael Konstan, the principal investigator of the Ohio Cardi-OHvascular and Diabetes Health Collaborative, also known as Cardi-OH, and I'm joined by Dr. Shari Bolen, co-principal investigator of Cardi-OH. Founded in 2017, Cardi-OH's mission is to improve Cardi-OHvascular and diabetes health outcomes and eliminate disparities in Ohio's Medicaid population. Cardi-OH brings together Ohio's seven medical schools to identify, produce, and disseminate evidence-based Cardi-OHvascular and diabetes best practices to primary care teams. To learn more about the collaborative and to access our online repository of best practices, please visit our website, Cardi-OH.org, and download our web app. I would like to acknowledge and thank our sponsor, the Ohio Department of Medicaid and our administrative partner, the Ohio Colleges of Medicine uh Government Resource Center. I would also like to uh recognize the partnership of Ohio's seven medical schools who contribute to make the Cardi-OH collaborative a success. Dr. Bolen will now provide some logistics regarding today's webinar.

[Dr. Bolen] Great. Thanks, Mike. um delighted to be here. Just a few logistics, if you um could please have your first and last name on your Zoom display. If you're joining as a group and have others in the room with you, if you could chat in their names and emails of the folks that are in the room with you. We hope you submit questions during the webinar. Um use the question and answer feature to submit your questions at any point and we will answer that during the Q&A portion of the webinar. And then we will have a survey afterward to um get your input as we work to improve our webinars over time. Next slide. We don't have any disclosures on the speaker side as well as the planning committee side. Next slide. If you're interested in CME, when you registered, you clicked that you were interested. So, if you haven't registered and you um want to get a CME uh credit, then go to this QR code and register and click that you're interested and then you will get a email from cloud CME within the next week for you to claim your credits. Um if you have any trouble, you can contact Kathy Sullivan. And with that, I'm going to introduce Dr. Zach, who will be moderating our webinar today and she'll introduce our speaker. Dr. Zach is a family medicine physician and vice chair of education at Cleveland Clinic and faculty at Case Western Reserve University School of Medicine. She serves as the lead of education and dissemination for Cardi-OH and we're delighted and lucky to have her in that role. Thank you Dr. Zach for moderating and getting us started with our speaker today.

Thanks so much Shari. It's my privilege to introduce our speaker today. Dr. David Holben is a professor of nutrition uh the Gillespie distinguished scholar and director of the office of food and nutrition security at the University of Mississippi. As a registered dietician, nutritionist, Fulbright scholar, and former US Army dietician, Dr. Holben has extensive experience working with disadvantaged individuals and households in rural communities including Appalachia, the Southern United States, and Canada. He has published dozens of peer-review articles and book chapters related to nutrition science, public health nutrition, and the social determinants of health. Currently, Dr. Holben is program director and principal investigator for learn science, an NIH and SIPA funded kindergarten through grade 2 life science and reading program run through public libraries to improve science achievement. He has had over $4 million in federal and state and industry funding for his work in nutrition-based STEM education for youth and in food insecurity. Dr. Holtin's career accomplishments were recognized in 2020 by the Academy of Nutrition and Dietetics with their Medallion Award. Today, we are privileged to have Dr. Hullen joining us to present identifying and addressing food insecurity in the medical setting.

[Dr. Holben] Well, thank you, Dr. Zach. It is an honor to be here, and although I am in Mississippi, my heart is in Ohio. I uh spent much of my career in Ohio. And thank you for inviting me to speak today. And today, we're going to identify and address food insecurity in the medical setting. And really, I think it's commendable that your group is interested in this because without food, what would our patients and clients do or where would they be?
So, the first thing I'd like to do is just for us to take one minute and I want you to write down or at least think about after our session today, I want to be able to blank. So, I'm going to give us one minute. All right. Thank you. I think that's really important because each of us are different. Each of us are in different medical settings and so identifying what you want to learn will hopefully direct some of your questions for the end of the session and to see if I answer or help you to achieve your goal today.

So, here are our learning objectives. After this talk, I hope you will be able to state the prevalence of food insecurity in Ohio and the United States. Provide evidence-based screening for food insecurity in the setting that you're in. Recognize national and local resources available to address food insecurity. And then to educate others on the impact of food insecurity on health and well-being.

So, I've never been in your shoes, but I'm not sure if you've ever been in this situation where your client, your patient says something about food and then you either say out loud or you think you don't have any food. And so hopefully we will make some strides towards what do you do when you're in this situation?
So if you don't remember anything else from today, I'd like you to remember these three things. Food security means food availability, food access, and food utilization. So those are three aspects of food security. Is food available in the community? Does that individual have access to that food? Usually with resources to buy it, and then food utilization.

When we look at our food system, we can actually layer these three concepts onto it. I'm not sure if you can see my arrow or not, but food availability relates to the food supply chain. Is food being produced? Is it being distributed? How is it processed and packaged? And what retailers and vendors are available? But when we think about food security in the medical setting, we're typically thinking about food access, the food environment. So, is food available? And do individuals have physical access? Do they have a car to go to the grocery store? Do they have to take two or three buses with their children in tow to get food? Do they have money to buy food? Do they have a federal benefit of some kind to help them access food? And then what's the food quality? What's the food safety like? What information do they have? And then finally, food utilization. What is their diet, their diet quality, their diversity, the safety of the diet? And then what health and nutrition outcomes are resulting because of that. So food availability, food access, food utilization.

So when we think about food security and food access, probably no matter where we go on the planet, this is a universal dimension of household and personal well-being. When your cupboards are bare, you don't really feel very good about your health probably. So this is all people at all times having access to enough food for an active healthy life. And this includes the ready availability of nutritionally adequate and safe foods and the assured ability to acquire them in socially acceptable ways. Sorry, my lights on a timer and it went off. So I apologize for that. So in other words, do your clients have to dumpster dive? Do your clients have to steal the food that they eat? Those things typically aren't considered socially acceptable in our culture.

So, these are the most uh recent estimates of food insecurity in the United States. These are measured by the Economic Research Service of the United States Department of Agriculture and they are measured every December. And so when we hear the unemployment statistics in the United States, those data are derived from the current population survey. And similarly, these data are also derived from the current population survey, but only in the month of December. And it has been this case since we started measuring food insecurity um since 1995. So the most recent estimates do say that about 13.5% of US households are food insecure. So that translates to about 18 million households. And so when we talk about food insecurity, these households were uncertain of having or unable to acquire enough food due to insufficient money or other resources.

Now in Canada they share a similar measurement strategy. They do have different cutoffs than we do but they call their food security income related food insecurity to underscore that it's resources that we're worried about. So if you're a picture person here is that in a graphic. So that's about 13.5%.
Now when we just look at households with children, we see that by having more mouths to feed in the household, food insecurity does increase. And so that goes up to almost 18%.

Now, unlike the obesity maps that the CDC has, the coloration is not consistent year after year. So, we you have to look at each graphic that they do and see what the patterns are. But one year they're purple, another year they're orange, yellow, and so, but we're looking at um the darker coloration. So these states have higher food insecurity compared to the US average. And we look at Ohio, we can see that Ohio is right around the US average, but we'll talk about that a little bit more. But states like Pennsylvania, Vermont, New Hampshire, out here in Minnesota, they have better food security than other states do.

Now for states the USDA takes 3 years and that is a moving window. So when the estimates come out in September October of this year for 2024 that window will be 22 through 24 because they don't have enough data in a single year to estimate the state accurately. Well, what about Ohio? So the US is 13 and a half%. What is Ohio? Ohio is right here. It's at about 12.8%. So, you can see that that's right around the US average, not statistically significantly lower. Um, it's just around that same amount. So, at 12.8% of you of households in Ohio are food insecure.

So, what other qualities influence whether people are food insecure or not? So, we can't necessarily tell a book by its cover, but there are some qualities that might raise red flags and say, "Oh, these individuals may be food insecure." And if we draw a line at where the US average is at around 13 12% and then we look at those qualities that are above that line, we can see a few different things. When households have children less than 18 years of age, when households have children less than six years of age, they are at higher risk for food insecurity. single headed households, whether it's a male household or a female headed household, both are at higher risk for food insecurity. It's very interesting when we look at the Canadian data. Uh male-headed households um aren't at higher risk for food insecurity, but female headed households are. Just like in the US, when women live alone and when men live alone, they're higher their risk is higher, more so for women. uh black and Hispanic households. Again, that's more about income level uh than um the individual's race and ethnicity. And then income, when someone is under 1.85% of poverty or lower, they are at higher risk for food insecurity. Now we will come back to this in a second but also if someone lives in an inner city or someone lives in a rural area they are at higher risk and then in the south as well.

Now related to income just to uh peique your interest with this uh 1.85% 85% that is the cut off for wick special supplemental nutrition program for women infants and children 1.3 that is the cut off for SNAP supplemental nutrition assistance program. So when we have clients patients that are food insecure they typically are going to exhibit some coping strategies. So they're going to make tradeoffs. They're going to have to choose maybe between buying their medication and buying their food, paying for their electric bill or buying food, paying for their air conditioning, their heating, whatever that might be, or buying food. They might just focus on less expensive foods and have a less varied diet because it might be easier to go through a drive-thru for $5, $4 to get a lot of calories uh rather than um buying wholesome foods, participating in federal assistance programs, food assistance programs. These are all voluntary in the United States. So even if you qualify, you don't automatically get a voucher or a coupon. You have to physically say or mentally say, "I need this. My family needs this. I'm going to apply." When people start borrowing a cup of sugar from their family or their friends, so they're seeking assistance when they go to an emergency food pantry or the food pantry down the street. So a food bank. Uh sometimes gardening is a coping strategy. We found some positive aspects of this. Um, and then sometimes people hunt, people fish.
So when we look over time, that this doesn't go back clear to 1995. This goes back to 2001, we can see that food insecurity es and flows. So food insecurity increased at certain time points here in the United States. And if you think back to 2007208, this is when we had a recession. And so you can see here 2021, this is when we had um our pandemic. Um now, uh it did not affect food insecurity. COVID didn't the way people thought it would. Um but there was an impact.

So from a health perspective and socio-familial perspective, food insecurity is associated with physical impairments related to insufficient food, psychological issues due to lack of access to food and socio-familial disturbances. The first group to really explore this was Hamlin and that reference is at the bottom. And then we can see that other researchers have uh confirmed these findings.

So what are some examples? So physical impairments might be a disease, fatigue or an illness, psychological issues, feelings of constraint to go against held norms and values, stress at home. So in other words, dumpster diving, stealing food at the corner store, socio-familial disturbances, modification of eating rituals, and so we're not going to have a turkey this year at Thanksgiving because we can't afford one, disruption of household dynamics, and then distortion of how food is acquired. And I mentioned this under the second bullet as well, but are are we dumpster diving?

If you look at some cities, they actually put locks on their dumpsters to prohibit people from doing that because they don't want to be held liable for these things.
So, the US has looked at some of these data with regard to chronic disease. I know most of you work in cardiology and diabetes uh family practice and so the US um did look at data Christian uh Gregory and Alicia Coleman Jensen and they looked at working age US adults and then all those adults were living at or below 200% of the federal poverty level.

So when we look at food insecurity, food insecurity is associated with a higher probability of these chron 10 chronic diseases. Asthma, arthritis, cancer, cardiovascular disease, COPD, diabetes, hepatitis, hypertension, kidney disease, and stroke. Now the ones on the same line, I just didn't have enough room for bullet points. So those are separate bullet points. So of those 10 conditions examined, food insecurity is predictive of all 10 and income is only predictive of three.

Sometimes we think, oh, if an individual has a lower income, we can predict things. But food insecurity is a better predictor than income with these chronic diseases.
So when we look at disabilities, um the CDC did look at this and they examined the relationship between food security in five categories of disabilities. Ambulatory, cognitive, hearing, vision, and mental health. I was really glad to see some people from disability services and Medicare Medicaid here. Um I'm glad to see that you're interested in this. And so adults with disabilities, especially mental health disabilities, are at a higher risk for food insecurity. Across the adult lifespan, across income levels, adults with disabilities are more likely to be food in to be in food insecure households than adults without disabilities. Again, in the United States, we measure a lot of these things at the household level rather than the individual level.

Okay. So, why does this matter? Well, hopefully um the things that I just mentioned related to chronic disease and also disabilities, uh FRAC uh does have a toolkit and this was sponsored uh by the American Academy of Pediatrics. So they um do look at this relates specifically to pediatricians and childhood diseases. But you can see above that there are several diseases poor health status, developmental risk, mental health problems, poor educational outcomes are all associated with food insecurity in the pediatric population. So we can see this at all age groups across the lifespan.

So, how do we screen for food insecurity? I think that's the question at hand. Some of your medical centers, your health care systems might already have this as part of your screening system. The first thing is to educate and train yourself. And I'm glad you're here today. And so then follow the American Academy of Pediatrics recommendations. Of course, this is for pediatricians, but these are universal things that you can do with adults as well. And I'll show you some other groups that do um screen and then incorporate these efforts into your uh practice and then just practice doing this. Teach your students to do this. I think it's important um that we introduce this to medical students early on and uh nursing students and other health care providers.

So, what I'm going to recommend is the hunger vital sign for you to incorporate into your practice. And several groups do advocate uh using this tool. So again, this can be found in that frac.org toolkit. So I would encourage you to access that frack.org and then it's the toolkit, AAP toolkit. So who does this? The American Academy of Pediatrics, the Academy of Nutrition and Dietetics also recommend this Medicare and Medicaid Services that is the uh blue [inaudible] um reference at the bottom. And then the American Medical Association, there are several um individuals who do uh advocate usage. Okay. and then start to screen.

Okay, how do we do that? So, I want to uh just read a quote from Hillary Selegman. Some of you may know of her. She's at um University of San Francisco Medical Center. I think she's one of the most well respected food security researchers. She is a medical doctor in the department of medicine and endocrinology in San Francisco. and she says this, "It is often difficult for parents to talk to clinicians about food insecurity in their household." So, I always start the conversation with food is important to your health. I want to make sure you have enough food and the right types of food. So, I ask all of my patients these questions. So this is definitely a sensitive issue just like other issues that uh primary care practitioners deal with and that quote is in that toolkit from Dr. Selegman. Uh and you can look up at PubMed um she has uh several publications especially related to diabetes.

So these are the two questions. These are simple only take less than a minute to ask. Within the past 12 months, you worried that your food would run out before you got money to buy more. Often true, sometimes true, never true. Often and sometimes are positive, meaning they're negative. And then never true is a negative response, meaning that's positive. And then within the past 12 months, the food you bought just didn't last and you didn't have money to get more. Is that often true, sometimes true or never true? Again, the often true or sometimes true trigger that client let's say getting a point and getting a point isn't good.

Now, these are two of the questions that also are part of those estimates that I talked about. That's part of the the current population survey. There are 10 questions for households with adults and then 18 questions for households with children. And on in all honesty, when I do research, I never ask the child questions uh because I think it uh some parents want to lie because they are a little embarrassed about their responses. And plus, I don't want them to think that I'm triggering something for child protective services that oh, they're not feeding their family. So, I just don't ask those. Um and the IRBs definitely um there's no questions about that, but both are validated.

So this would be up to you. But these are two questions from the 10 or the 18 item food security survey that both the US and Canada uses. These two were validated by Hagar and others in 2010.
So here is a potential add-on. within the past 12 months, have you used a food bank, a food pantry, an emergency food kitchen? So, yes, again would be a positive response or a negative quality. And so, um, because people voluntarily go here, they're saying, "I need food."

Okay. So if you see positive responses to these questions then what do you do? Now hopefully if your health care system u medical center has these as part of the screening when patients are admitted that you already have something in place. So this is what we would do if a family a person says yes to these.

By the way, some of these fruit and vegetable pictures were taken in Ohio. That first one that I showed you was from a produce auction where Amish and English farmers do sell their produce to establishments, restaurants, hospitals, other places uh in Ohio. And then this is from the Athens farmers market. And this farmers market accepts Wick and Senior Farmers Market nutrition program vouchers. And that's where coupons are given to uh clients so that they can access fresh fruits and vegetables at the market. This market also accepts SNAP, Supplemental Nutrition Assistance Program. So near you, there are probably community-based programs, definitely federal programs, and ways that you can improve food insecurity.

When I was in Athens, we did uh develop handouts for family practice positions that they could have in their office so that they could then give them to clients to say this is how you apply for school lunch program. This is where you can get food at a food pantry. And so we gave the uh the physicians gave these to the clients so they would have practical ways to help their clients.

So these are some of the programs that we did put on handouts. So that supplemental nutrition assistance program or SNAP. This is we're hearing a lot about this in the news because of the voucher um programs or I not voucher uh well anyway prohibiting uh soda pop but allowing rotisserie chicken and some states are signing on to that. Then special supplemental nutrition program for women, infants, and children. We call that wick. Now, SNAP is an entitlement program, meaning if your client has a certain income based on a certain family size, they automatically qualify or are entitled to this program, but it's not automatic. They have to go sign up for it. Whereas WIC is a uh a nutrition program and so they have to have a nutrition problem.

If I interviewed all 400 of us today, I could identify a nutrition problem in everyone. And so it's really easy for people who qualify based upon their income to qualify for WIC because they will have a nutrition problem as well undoubtedly. Um now how does WIC and SNAP differ? Well, wick gives particular foods that the clients are permitted to uh purchase with their wick voucher. So, it says if you are a child less than five, you can get this, this, and this. If you're a woman who's pregnant or lactating, you get this, this, and this. If you choose to breastfeed rather than to have formula, you get this. So it is going to specify the foods that must be purchased uh at the grocery store, bodega, whatever it would be.

Childcare meals. So there are uh meals that daycare centers can qualify for. Of course there's head start, school breakfast and the lunch program, afterchool meals, summer nutrition program. This is not available in all communities, but then um it is available in many. And this is when meals are provided at, let's say, libraries or schools or other places. Now, this specifically mentions the pandemic, but we can just talk about disaster situations. If there is a disaster in a community, and you'll hear this on the news, it will say that disaster SNAP has been activated. And so then everyone qualifies regardless of the income. So after 9/11, executives with very high incomes still qualified for SNAP in New York City because of the disaster situation.

So what can we do to combat food insecurity? Well, I would say refer those in need to appropriate federal and local programs. So I would encourage you to explore what programs are in your community. Are there some foodbased programs at churches, recreation centers, schools, um health clinics? Are there some economic assistance programs? So, are they um helping people to improve their economic well-being through job training or whatever it might be.
So the grant that I mentioned uh or that was mentioned in my bio uh we are actually um doing science education in children K through two so that they can be equipped uh with science knowledge. Hopefully they will then choose science, engineering, medical careers to improve their economic uh well-being as they grow into adulthood. and also can they make better health care decisions because they understand the science behind um medicine and then how do people access them and so I think we all can do this you don't have to be a social worker to teach people about these programs I think we can all help clients to access them but we do want to partner with social workers with registered dieticians we do want to network with each other what are you doing? How can you collaborate maybe with a food as medicine program in your health center community? And then can we be advocates? And I think advocacy and public policy is arguably everybody's business. And um buses stop at railroad tracks now because people thought it was a problem when the buses were getting hit. And so we've all watched Schoolhouse Rock probably as kids and know how a law becomes a law.

Okay. I wanted to leave some time for questions, but before we do that, um I want to uh just have you look back at what you wrote down and say, "Did I achieve my goal? Didn't I achieve my goal? Can I state these things that uh Dave said we were going to be able to do at the end of the session? Can I state the prevalence of food insecurity in the US? That's 13.5. Uh can I state the prevalence of food insecurity in Ohio? 12.8. And um can I list the two questions when screening for food insecurity? What's one national resource that I have in my community? What's one local resource that's available in the city where I live? What's one negative outcome of food insecurity or one negative association of uh food insecurity on health and well-being? And then how do you plan to implement screening in your medical setting?" And I'm going to give you one minute to think and then we will just start the questions. So get your questions ready and after this minute.

All right. So um Dr. Zach and company will be um monitoring the the questions and so uh those are my references. Uh please feel free to use those and contact me if you have questions. So Dr. Zach and team, what questions are arising?

[Dr. Zach] Thank you for that excellent discussion. Um, we do have a few questions and a reminder to those who have questions, please use the Q&A feature as opposed to the chat. Um, if you are able to, um, to start with, we have, um, someone who says they're in Wisconsin at a local health department. They've been using the term nutrition security, having the right calories rather than food security, having enough calories. Nutrition security encompasses food security, but also addresses diet quality and uh and equity. Um recognizing structural inequities make it hard for people to eat healthy as you mentioned. What are the what is uh your thought on using this term nutrition security rather than food security?

[Dr. Holben] All right. Uh thank you for that question. So often times those two terms are used interchangeably but as you note uh nutrition security is different than food security. And so I I think that's good. Uh practically speaking, it is often difficult for people to access enough food, let alone saying, "Oh, wow. You need to access these particular foods in order to be healthy." So, of course, we do want to encourage people to make those healthy choices. And this is probably one of the biggest controversies related to the SNAP um issue in our country right now.

For example, should soda pop cola be prohibited on SNAP? And so when I look at that as a registered dietitian, I say, "Oh, sure." Because supplemental nutrition assistance programs. And yet, if I'm homeless or I don't have a refrigerator or if I'm a a person with diabetes and don't have access and don't have access to food or I'm sick and can't eat, drinking soda pop might be a good way to maintain my blood sugar. If I'm homeless, that's something that doesn't spoil. So, I think this is why there is a controversy with um let's say requiring people to choose healthy foods. But I I think it's a good practice and uh I think educating people on how they can wisely spend their SNAP dollars and um have a more nutrient-dense diet, but yeah, it is a touchy issue.

Are there any early projections for impact on food insecurity as a result of the current administration's policies? Well, if you look at the food security numbers, um, you know, they don't necessarily fluctuate with administration. Um, they usually fluctuate with economic problems. So, no, there is not any projections. We will measure these numbers in December of 2025. Um, and so we'll see uh what happens with a a change in policy A, B, or C. And so, uh, so the shorter answer is no.

[Dr. Zach] Thank you. Do you have any perspective on the new US PTF guidance around uh screening and intervention for food security?
[Dr. Holben] You know, I'm not sure I'm familiar with that. So, could they clarify that a little bit? What's the acronym again?

[Dr. Zach] The US um US Preventative Task Force, US PTF.
[Dr. Holben] Okay. No, I I'm not sure what they're using for screening if I'm being totally honest. And so, if I knew what they were using, I maybe could react. Um, so I I don't have an answer for that. I'm sorry.
[Dr. Zach] You know, if the person who asked that wants to clarify in Q&A, feel free. Um, how do we create a safe space for parents to speak honestly about needing help with food insecurity in their homes? Many don't speak out in fear of being reported as you mentioned earlier.

[Dr. Holben] Yeah, that is really key. I think establishing trust uh with the client is really important. Uh I was a pediatric dietician uh from 1987 to 1992 at two major pediatric institutions in our country and really establishing rapport and trust among the clients is first and foremost. And um and we yet we do see neglect sometimes when people are skipping meals. Uh so uh but I think establishing trust is important and again I just don't ask those questions. I ask the questions about the adults in the household or the households in general and then can make inferences um from that.

um is there a limit um to that you're aware of to food bank utilization? So how many times you could go to a food bank, how many food banks you can visit? um you know are there limitations to accessing those types of services?
Uh thank you for that question. That's all going to be uh food pantry specific. And so let me I'll just give some technical nomenclature. Uh so the food bank is the huge parent warehouse where food is stored and then made available to food pantries. And so commodity foods might be sent to the food bank and then the food pantry goes and buys or gets those donated, however it works. And so uh a food pantry is the local community system. So we have a food pantry here on our university campus. It's not tied to a food bank. So all they use all donations either by money or food to supply that. And so, uh, some churches, some food pantries might have rules, whereas others don't. And so, that's all going to be food pantry specific, and that's something that you could help your clients figure out and just ask the policy of the food pantry in your community. So, that's all going to just vary by community. There's no national standard.

So just to um loop back on the task force recommendation um you know a couple folks have posted it um and what I can share is that the US uh preventative service task force concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for food insecurity on health outcomes in the primary care setting. Um, so while if you haven't had the opportunity to read the report, asking you to comment on it is probably not um, reasonable, I just wanted to share that with everybody who is joining um that, you know, while they're sort of saying the evidence doesn't support it, it's really uh, there's not adequate evidence to say for or against um, at this time per the US PTF um, guideline. So, um, and the link is there. Um, if you'd like to look at the webinar chat, you can read it for yourself. So, for anybody who's interested, um, but how, Dr. Holam, would you, um, would you say when we have folks telling us the evidence doesn't support screening, um, kind of what would be your answer to that in our institutions and, um, clinics and settings where we're trying to advocate for this type of work?
Okay. Well, if the evidence doesn't support it, the evidence doesn't support it. But I would say maybe we need more evidence. So, is there a study that I can do in my medical center? Is there something that we can do across the state to get more evidence? And so, I would say first contribute to the evidence. Second, these are validated questions. These two questions do seem to they do how can I say translate well to the validated measure the the larger one that the USDA uses and so I think it can give you information about your client and if they don't have access to food and it's as simple as asking two questions that take less than a minute then I would say why not Um, I guess that's what I would say. Um, can I contribute to the evidence and then why not ask it?

[Dr. Zach] Um, thank you. Um, we have time for just a couple more. Um, one of our folks said, "I work with FQC's on chronic disease management and many don't have dietitians or nutritionists to guide patients on what to eat for diabetes or hypertension. I have found this is a gap. Any ideas on how to connect patients to this service?"
[Dr. Holben] Um, the service of of dieticians and social workers, I guess.

[Dr. Zach] Yeah, I think dietitian or nutritionist where they don't have access to it in their local clinic or community setting.

[Dr. Holben] Yeah. So, I think this is a matter of establishing partnerships and collaboration. I I think it's also a matter of policy and advocacy. If you see this as a need, then you probably I think I hate to say probably. I think this is an opportunity to talk to your national representative and your state representatives to see if that can be incorporated into what is covered uh by um the insurance program that that client uses. Um yeah and then of course there are certified diabetes educators where the scope of practice you know they can maybe comment now you know I'm an advocate for dieticians um but yet if a person has training and their scope of practice permits them to practice in that area then I would encourage that u is maybe an opportunity as well but I would say advocacy and partnerships.

Wonderful. Thank you. Um, for folks that would like to start a food program, maybe a pantry, a food giveaway at their institution or clinic or site, how do you recommend that they might get started with this process?
Okay. Well, a food pan Wow, these are some great questions. I didn't anticipate. Okay. So, if you are going to have a food pantry, you have to think, what do I need? Well, you're going to need space. So, that would be one of the first steps. You're going to need potentially refrigeration as well. You're going to need an area where people can come and have dignity and feel good about going there. So, that's the first thing. Do you have the space to do that? Then you have to think, well, how is this going to be funded? And so if I contact my the Mid Ohio food bank, what would it take for me to get food from them for that food pantry? Um or do is there a foundation in place that we can use? Is there funding available somewhere to establish this? And then as was asked before, what will the policy be? Can this be every time the client comes to the clinic or is it only monthly or whatever that might be? So, I would look at that. And then if you're working with clients who have physical uh problems, um is there a way for them to get the food home? Are you going to deliver that food? So, there's a lot of logistics, I think. Um also, nomenclature matters. Um I believe I'm correct with this. I don't want to quote the statute verbatim, but the word pharmacy is a protected term whether it's with an F or a PH. And so you can't have a food pharmacy at your medical center because that violates the Ohio statute because the pharmacists have said that tended that tends to indicate the practice of pharmacy. And so you'll want to make sure that you name your facility appropriately as well. So, I would say space and then funding and then also who is going to actually do this? Um, who's going to pass out the food?

[Dr. Zach] Do you have any thoughts around the idea of kind of the utilization of food prescription or that the idea of of that type of thing? Um, so you know, kind of making directed recommendations to folks about what to what foods to access and and what to eat.

[Dr. Holbin[ Well, I'm not an expert in this area, but I think the evidence is suggesting that um there are some benefits to having a food prescription as far as diet quality. Again, I don't want to overstate it because I did not look at the evidence for that for this talk, but um it almost legitimizes healthy eating. And so I think our patients, our clients take what we say seriously. And so, um what I think our words, whether they're written or verbally, probably are taken seriously. Um, but I think that's all I'll say. There are probably other experts in this virtual room that could answer that question better than myself.

[Dr. Zach] Thank you. Um, well, I think um that that takes care of most of our questions today and um I don't know if you have any final thoughts to wrap up. Um the the kind of last couple questions that we had echoed folks concern about access to resources and how do we prepare our clients or patients um for potential change in access to food resources? Is there something that we should be recommending to them, a way for them to prepare, something for them to do um so that you know if their benefit changes unexpectedly, they they are able to manage that.

[Dr. Holbin] Sure. Um you know, we often we try to anticipate these changes, but we're wrong most of the time. Uh what comes to mind is refer your clients to Susie Orman. You know, I hate to say that, but uh you know, learning how to manage resources is a vital skill for people to do. Uh it's a shame that we don't have home economics programs in many many high schools anymore. So I think helping clients to manage their resources and if you read the position paper of the academy of nutrition and dietetics uh helping clients to improve their economic self-sufficiency is one of the best skills we can teach them to improve food security and so helping our clients to make wise choices with the resources that they do have I think is important and again availability food access food utilization and thank you for being here. It just shows I think your interest in this important topic.

[Dr. Zach] Absolutely. And do you know of any resources where we that we might use in working on that economic um understanding or sufficiency for patients?

[Dr. Holbin] So I think there will be community based programs that that is their whole mission. I would look at those. Is there a workforce development program that people can access? Um, is there a financial management program just learning to manage resources? Um, I think it's called money bank is the one in high schools that are utilized. So maybe are some colleges and universities partnering with high schools to teach just basic financial literacy. I think that's really important. Um, but I guess that's all out and and really there's advertising at stores that will try to encourage clients to buy things that are not food-based or to buy unhealthy foods. And so we have to teach clients to navigate that system.

[Dr. Zach] Wonderful. Thank you. And uh I do want to mention that one of our folks in attendance recommended a website called freshtrak.com. Um and you can enter your household zip code and it helps to identify food resources. So um great resource. Thank you for sharing that with all of us. And um with that I want to uh extend a huge thanks to Dr. Dr. Holbin for being here and speaking with us today on this hugely important topic. Thank you. You're welcome.

[Dr. Bolen] Thank you Dr. Holbin. A wonderful talk. Uh thank you Dr. Zach for moderating. Um you can move to the next slide. We'll just go through. Um, so just a reminder that if you wanted to claim CME to make sure you've registered um and you've expressed that you're interested in CME so you can get that and you can use this QR code um and they'll put a URL in the chat as well. Next slide. Um, and we do want to hear from you about how we can improve our webinars and other future topics. So we will send out a brief survey after this webinar and would love for you all to uh let us know how it went. Next slide. Um so again, thank you to our speakers, moderators, and also thank all of you for joining with us today. Um if you're interested in learning more about Cardi-OH, you can visit us on Cardi-OH.org or follow us on social media. Um we have a monthly newsletter that comes out and I think somebody asked about the slides which those will get posted on our website as well. So thank you all and have a wonderful rest of your day.